# LIBRARY OF CONGRESS. I 

| jfcfV&ZCX I 

# . I 

I UNITED STATES OF AMERICA. J 



t 

OBSTETRIC APHORISMS: 

FOR THE 

USE OF STUDENTS 

COMMENCING 

MIDWIFERY PRACTICE. 



BY 
JOSEPH GRIFFITHS SWAYNE, M.D., 

PHYSICrAN ACCOCCHEUR TO THE BRISTOL GENERAL HOSPITAL, AND LECTURER 
ON OBSTETRIC MEDICINE AT THE BRISTOL MEDICAL SCHOOL. 



SECOND AMERICAN 

FROM THE 

FIFTH REVISED ENGLISH EDITION, WITH ADDITIONS. 
BY 

EDWARD R. HUTCHINS, M.D. 




motf 



PHILADELPHIA: 

HENET C.LEA. 

1813. 






Entered according to Act of Congress, in the year 1872, by 

HENEY C. LEA, 

in the Office of the Librarian of Congress. All rights reserved. 



COLLINS, PRINTER. 



TO 



JOHN ALDINGTON SYMOEDS, M.D., F.R.S.E, 

CONSULTING PHYSICIAN TO THE BRISTOL GENERAL HOSPITAL, 

f Ijis Wisxl is Jjriiicatrir, 

AS A MARK OF RESPECT FOR HIS HIGH ATTAINMENTS, 

BOTH PROFESSIONAL AND GENERAL, 

AND OF GRATITUDE FOR MUCH VALUABLE CLINICAL INSTRUCTION 

AND FOR MANY ACTS OF KINDNESS, 

BY HIS FRIEND AND FORMER PUPIL, 

THE AUTHOR. 



EDITOR'S NOTICE. 



A little over two years ago the first Ameri- 
can Edition of this work was given to the pub- 
lic. The Editor desires to express his sincere 
thanks to the medical journals and press which 
have so very kindly noticed his simple but 
practical suggestions, and to the many young 
practitioners and students, who have signified 
their welcome of its issue. His additions to 
this are inclosed in [ ] brackets, and it is 
hoped that this little work — so valuable abroad 
— may be thought none the less of in its second 
American edition. 

E. E, H. 

Cedab Rapids, Iowa, 
September, 1872. 



1* 



PREFACE. 



The object of this work is to give the student 
a few brief and practical directions respecting 
the management of ordinary cases of labor ; 
and also to point out to him, in extraordinary 
cases, when and how he may act upon his own 
responsibility, and when he ought to send for 
assistance. It has been undertaken by the 
Author in accordance with a wish often ex- 
pressed to him by his pupils, and is founded 
upon his experience of the wants of those who 
are commencing midwifery practice. The stu- 
dent is never placed in a more trying situation, 
nor has to incur a greater amount of responsi- 
bility, than when he is attending a difficult 
case of labor in a place remote from medical 
aid. Should this work serve to keep any, who 
may be so situated, from the opposite extremes 



Vlll PREFACE. 

of temerity or timidity, 1 its end will be fully 
answered. It is not intended to be used, in any 
way, as a substitute for a systematic treatise 
on midwifery, and therefore many details in 
anatomy, physiology, pathology, and treatment 
have been purposely omitted. 

It w T ill be observed, that the student is ad- 
vised to send for assistance whenever it is 
necessary to use instruments or to introduce 
the hand into the uterus for the purpose of 
turning, etc. ; and, indeed, in all cases which 
are necessarily dangerous, and accompanied 
with more than ordinary difficulty. The diag- 
nosis of such cases is, it is hoped, given at suf- 
ficient length to enable him to know w T hen he 
ought to send for aid ; but the treatment is in- 
dicated in as few words as possible, because a 
fuller account of it would cause this book to 
exceed the limits of a work which is merely 

1 For instance, the student who undertakes a case of 
placenta praevia without sending for assistance, is an ex- 
ample of one extreme ; and the student who sends for 
help to remove a detached placenta from the vagina, of 
the other. 



PREFACE. IX 

intended to serve the temporary purpose of a 
guide to beginners in the Obstetric art. 

The Author has only to add, that he feels 
most grateful for the favorable manner in which 
the former editions of this work have been re- 
ceived, especially amongst the junior members 
of the profession. In the present edition he 
has done his best to improve on the preceding, 
although in a manual consisting of short and 
well-established rules for practice there is not 
the same room for additions and alterations as 
in a larger work of more theoretical character. 
Nevertheless, it will be found that, besides 
several minor alterations, some important ad- 
ditions have been made to the text of the pre- 
sent work, especially in relation to secondary 
hemorrhage after delivery, the treatment of 
perineal lacerations, the pathology and treat- 
ment of pelvic cellulitis, and the use of hydrate 
of chloral in insomnia, convulsions, and other 
puerperal affections. 

With respect to the illustrations in this 
work, it may be mentioned that, with the 
exception of four, they are taken from the 



X PREFACE. 

author's original drawings. For one in par- 
ticular (ISTo. 8), he is indebted to Dr. Tyler 
Smith, who most kindly permitted him to use 
one of the engravings from his own " Manual 
of Obstetrics." 



CONTENTS. 



PART I. 

PAfiE 
THE MANAGEMENT OF ORDINARY LABOR ... 13 

PART IT. 

CASES WHICH THE STUDENT MAY UNDERTAKE WITH- 
OUT ASSISTANCE 51 

PART III. 

CASES IN WHICH THE STUDENT OUGHT TO SEND FOR 

ASSISTANCE 118 

PART IY. 
CHAPTER I. 

DISEASES OF PREGNANCY 158 

CHAPTER II. 

CARE OF THE NEW-BORN INFANT . . . .164 

CHAPTER III. 

ABORTIONS 173 



LIST OF ENGRAVINGS. 



PAGE 

Fig. 1. — First stage of labor — Mode of making vagi- 
nal examinations 21 

Fig. 2. — Normal position of the foetus in utero . 23 
Fig. 3. — The cavity of the uterus with the parturient 

canal in a state of full dilatation ... 28 
Fig. 4. — Ordinary position of the foetal head at the 

commencement of the second stage of labor . 30 
Fig. 5. — Position of the head during the second stage 31 
Fig. 6. — Position of the head towards the end of the 

second stage 32 

Fig. 7 (1). — Shape of the os uteri in occipito-pos- 

terior position 62 

Fig. 7 (2). — Shape of the os uteri in occipitoanterior 

position 62 

Fig. 8. — Expulsion of the head in occipito-posterior 

position 65 

Fig. 9. — Expulsion of the head in face presentation 66 
Fig. 10. — Ordinary position of the foetus in breech 

presentations 69 

Fig. 11. — Extraction of the arms in breech presenta- 
tions 73 

Fig. 12. — Extraction of the head in breech presenta- 
tions 74 

Eig. 13. — Position of the head in vertex presentation 128 
Fig. 14. — Position of the head in brow presentation 129 
Fig. 15. — Position of the head in face presentation. 130 
Fig. 16.— Presentation of the arm (Churchill) . 132 



OBSTETEIO APHOEISMS. 



PART I. 

THE MANAGEMENT OF ORDINARY LABOR. 



Importance of Prompt Attendance. 

1. When sent for to a labor, obey the call imme- 
diately; for then, if you are too early, you can 
return home until wanted ; and if you are too late, 
it is not your fault. 

Delay may occasion, 1, various accidents to both mother 
and child, from sudden delivery without assistance ; 2, the 
loss of the best opportunity for rectifying mal-presenta- 
tion ; 3, the loss of the patient's confidence in you, and 
the substitution of another practitioner. 

Instruments and Medicines which may be required. 

2. You may take with you a stethoscope, and 
also a pocket-case containing blunt-pointed scis- 
sors, a silver or gum-elastic female catheter, curved 
needles, silver wire or silk for sutures, ergot of 
rye, laudanum, oil of turpentine, and sal volatile. 

2 



14 MANAGEMENT OF ORDINARY LABOR. 

With the exception of scissors, none of these things 
will be wanted in an ordinary labor; but it is right to 
be provided with them against emergencies. Cases con- 
taining them may be procured at any surgical-instrument 
maker's shop. 

The needles and sutures will be necessary if the peri- 
neum be lacerated. (See 70, Part II.) 

It is a good plan to carry ergot both in the form of 
fresh powder and tincture, in case, as often happens, one 
of these preparations should prove to be inefficient. 

The Extractum Ergotae Liquidum [Extractum Ergotse 
Fluidum, U.S. P.] of the British Pharmacopoeia can, how- 
ever, be depended on in most instances. 

Oil of turpentine is not usually carried in a pocket-case; 
but the author has found it of great efficacy in uterine 
hemorrhage. 

[The young practitioner never should go to the bedside 
of one in confinement without the forceps.] 

Preliminary Observations. 

3. On first seeing your patient, do not abruptly 
question her respecting her symptoms, but con- 
verse on some ordinary topic, and whilst thus 
engaged, notice any indications of pain in her 
countenance, the tone of her voice, or the charac- 
ter of her respiration. 

A brusque, abrupt manner of putting questions may 
flurry a patient so as to cause her pains to be suspended 
for a considerable period. 

In general, the first stage of labor is characterized by 
low complaints, and an absence of voluntary effort; and 
the second stage by deep inspirations, a loud outcry, and 
strong exertions of the voluntary muscles ; and thus an 
attentive observer may form a rough estimate of the pro- 
gress of a labor. 



MANAGEMENT OF ORDINARY LABOR. 15 

Questions respecting Pregnancy, Previous 
Labors, etc. 

4. Before making more special inquiries, 3 t ou 
may ask respecting the patient's constitution and 
state of health during pregnancy, and (if she be 
not a primipara) the number and character of her 
previous labors. 

A knowledge of these circumstances may enable you to 
calculate the duration of the present labor, or to anticipate 
the occurrence of difficulties or complications requiring 
the assistance of art. For instance, if a woman of middle 
age be in labor for the first time, a lingering labor may in 
general be expected ; or if it has been necessary in all the 
previous labors to deliver by instruments, or if post-partum 
hemorrhage has regularly occurred, you may expect simi- 
lar untoward events in the present labor. 

[The principal cause for the lingering labor incident to 
the middle-aged woman (primipara) is the immobility 
of the sacro-coccygeal joint. After thirty or thirty-five 
years, if the woman has not given birth to offspring, this 
joint becomes synarthrodial, the coccyx thus offering a 
serious impediment to the progress of the labor. Under 
such circumstances, the ossified uuiou may be fractured, 
and require subsequent treatment.] 

Questions respecting the Present Labor. 

5. The questions to be asked respecting the pre- 
sent labor are — when the pains were first felt, and 
where {e. g., whether in the back or abdomen), 
their character, duration, and frequency; and, last 
but not least, whether they have been attended 
with any " show" or discharge of mucus tinged 
with blood. 



16 MANAGEMENT OF ORDINARY LABOR. 

A consideration of all these particulars will assist you 
in ascertaining whether the pains are genuine, and whether 
the labor has actually commenced. 

The show denotes the opening of the os uteri, and is 
one of the most certain signs of commencing labor; it is, 
therefore, made of much account by nurses. 

How to propose a Vaginal Examination. 

6. The only certain information, however, re- 
specting a labor, is derived from a vaginal exa- 
mination, which should be made as soon as possi- 
ble, provided the pains are at all regular. You 
accordingly signify to the patient, either directly 
or through the nurse, that you wish her to lie 
down on the bed, so that you may be able to try 
the next pain, and inform her as to the progress 
of the labor. 

If your patient shows an unreasonable reluctance to 
submit to an examination, you may tell her that, for all 
you know, the labor may be going on very badly, and that 
you will not be answerable for the result; by thus work- 
ing upon her fears you will seldom fail to obtain compli- 
ance with your request. 

How to make a Vaginal Examination. 

1. In order to make a vaginal examination, 
direct the woman to lie on the right side of the 
bed, but upon her left side, with the knees drawn 
up towards the abdomen ; sit down behind her, and 
pass the forefinger of the right hand (previously 
anointed with oil or lard) into the genital fissure 
close to the perineum ; then direct the finger first 



MANAGEMENT OF ORDINARY LABOR. 17 

backwards towards the lower part of the sacrum, 
and then upwards and forwards towards the pubis, 
so as to reach the os uteri, and presenting part of 
the child. If the os uteri is high up and far back, 
the fore and middle fingers of the left hand may 
be substituted for the right forefinger, because they 
more readily follow the curve of the sacrum. 

Amongst the lower classes, women Usually wear their 
ordinary clothes until the labor is over, when they are un- 
dressed and put to bed. 

Vaginal examinations and other necessary manipula- 
tions are to be made beneath the clothes of the patient, 
whose person should be in no way exposed. 

After examining, the fingers should be wiped in a nap- 
kin, provided for the purpose, and placed beneath the 
bedclothes. 

It is as well to caution a beginner against passing his 
finger into the anterior part of the genital fissure, as, by 
so doing, he may fail to find the entrance of the vagina, 
puzzle himself very much, and annoy the patient, who 
may thus discover that she has been intrusted to a very 
young hand. 

If the fore and middle fingers of the left hand are used., 
they should be introduced as the forefinger of the right 
hand is being withdrawn. 

When to Examine. 

8. In general, it is better to examine during a 
pain; but an examination, to be complete, should 
be made both during and after a pain ; during a 
pain (if the labor be in the first stage) it should 
be strictly limited to the os uteri, vagina, and sur- 
rounding parts, When the pain is over, and not 
2* 



18 MANAGEMENT OF ORDINARY LABOR. 

until then, the finger may be passed through the 
os uteri, in order to examine the presentation. 

Any attempt to make out the presentation when the 
membranes are rendered tense during pain, will in all 
probability cause their rupture, an accident always to be 
avoided in the first stage of labor, especially .if the pre- 
sentation be at all unfavorable— see Part III., 12 and 16. 
When the pain is over, the membranes and os uteri 
become flaccid, and the presentation is much more easily 
distinguished. 

[As a general rule, examinations should be made in the 
absence of a pain.] 

Information derived from Examination. 

9. The information derived from a vaginal exa- 
mination is very complete, for by it you learn — 
i. Whether the passages are in proper condition for 
labor, ii. Whether labor has actually commenced, 
iii. Whether it is in the first or second stage, iv. 
Whether the presentation is natural, v. Whether 
you can leave your patient for a time with safety. 

State of Passages, etc. 

10. i. When the passages are in a proper con- 
dition for labor, the pelvis is roomy, with the os 
uteri in its centre ; both the os and vagina are 
soft, dilatable, moister than usual, and sometimes 
plentifully bedewed with mucus ; the canal of the 
vagina is neither encroached upon by the rectum 
and its contents behind, nor by the bladder in 
front ; its walls are rugose in primipara, but much 
smoother in multipara, especially at its upper 



MANAGEMENT OF ORDINARY LABOR. 19 

extremity, where its calibre is also greater ; its 
temperature is not raised, nor is it tender under 
an ordinary examination. 

In a pelvis of normal dimensions, the shortest diameter 
should not be less than four inches, and it should be im- 
possible to touch the upper part of the sacrum with the 
finger, in an ordinary examination. 

fit has been found by comparison of a large number of 
pelves that those of American women are a trifle larger 
than those of foreign subjects, and the same remark is 
true of fcetal cranii — those of American being a little 
larger than those of foreign parentage.] 

In multiparse, the os uteri is usually situated more ante- 
riorly than in primiparse, in whom it is sometimes so high 
up and far back, at the commencement of labor, that it is 
scarcely possible to reach it, unless you examine with two 
fingers of the left hand. 

With respect to the mucous secretion, Wigand remarks 
that "the more albuminous it is the better, and it is always 
a good sign when lumps of albuminous matter come away 
from time to time ; the thicker, softer, and more cushiony 
the os uteri is, the more mucus does it secrete." 

Signs of Commencing Labor. 

11. ii. Labor is known to have actually com- 
menced by the occurrence of pains, which return 
at regular intervals, and increase in frequency and 
force, and which, on making a vaginal examina- 
tion, are found to be attended with a mucous show, 
and to have caused more or less dilatation of the 
os uteri. 

During the ninth month of the pregnancy, the uterus 
usually sinks somewhat in the abdomen, and this subsi- 
dence, while it relieves the respiratory organs, causes 
pressure upon the rectum, bladder, and other contents of 
the pelvis, occasioning frequent desire to pass water and 



20 MANAGEMENT OF ORDINARY LABOR. 

go to stool : these symptoms are so usual, that they have 
been considered as premonitory signs of labor. 

In multipara;, the os uteri is sometimes so open before 
the actual commencement of labor as to admit the tip of 
the index-finger, and even to allow the presentation to be 
distinguished. 

In primiparse, it is usually closed until labor has actu- 
ally begun. 

Signs of First Stage. 

12. iii. a. The first stage of labor is occupied 
in the dilatation of the os uteri. This process is 
effected solely by the contractions of the uterus, 
unaided by any of the voluntary muscles. It is 
characterized by peculiar cutting or grinding pains, 
first felt in the back, and gradually extending to 
the front. 

State of Os Uteri, etc., in First Stage. 

b. On making a vaginal examination, you can 
feel that the upper part of the vagina is occupied 
by a soft, rounded tumor, formed by the lower 
portion of the uterus. (Fig. 1.) In the centre of 
this is the circular aperture of the os tincse, dilated 
to the size of a sixpence, shilling, half-crown, 
crown, or even larger; and within the os can be 
felt the membranous bag of the waters containing 
the presenting part of the child. When a pain 
comes on, the os uteri becomes thin and tense; 
the bag of the waters, which was before flaccid, 
becomes globular and tense as a drum, and pro- 
trudes more or less through the os, which is thus 



MANAGEMENT OF ORDINARY LABOR. 21 

most effectually dilated. As the pain increases, 
the presenting part descends and presses upon the 
os uteri. 

Fig. 1. 




Old nurses often imagine that the pains of the first 
stage, which they call iJ niggling" pains, are doing no good, 
and will accordingly direct their patients to hold their 
breath and to bear down with all their might. This pro- 
ceeding is not only useless, but injurious, as such exer- 
tions of the voluntary muscles are premature, and only 
tend to prod ace exhaustion. 

If the hand be placed upon the abdomen during a pain, 
the whole uterus will be felt to become very firm and hard 
under contraction. 

In primiparge, the circle formed by the os uteri during 



22 MANAGEMENT OF ORDINARY LABOR. 

dilatation feels much thinner, sharper, and more even than 
in multipara, in whom it is often irregular, and thickened 
from the effects of previous labors. 

Sometimes the child's head, covered by the anterior lip 
of the os uteri, presses down low into the pelvis even before 
the commencement of labor; and in such a case, a begin- 
ner, mistaking it for the bare head, may erroneously con- 
clude that the labor is far advanced in the second stage. 
A careful vaginal examination will prevent any one from 
falling into this mistake, for, even if the undilated os uteri 
is not detected, it will be found that the finger cannot be 
passed between the presenting body and the pelvis beyond 
a certain distance, viz., the angle formed by the junction 
of the vagina and the uterus ; whereas in the second stage 
of labor the finger may be passed as high between the 
head and pelvis as it will reach. 

Diagnosis of Presentation. 

13. iv. The presentation should always be made 
out, if possible, before the membranes are rup- 
tured. The ordinary and natural presentation is 
that of the crown of the head, or vertex. This is 
recognized by being larger, rounder, and harder 
than any other, but above all, by the divisions or 
sutures, and spaces or fontanelles between the cra- 
nial bones. (Fig. 2.) 

If the presentation be not recognized until after the 
membranes are ruptured, the most favorable opportunity 
for turning or otherwise rectifying malpositions is lost. 

In multiparas the head is usually much higher during 
the first stage than in primipara3; and it occasionally lies 
so much in front and above the pubis, that there is con- 
siderable difficulty in reaching it before the membranes 
are ruptured. 

When the sutures and fontanelles can be distinctly felt, 
it amounts to positive proof of head presentation, as no 
such structure exists in any other part of the body. 



MANAGEMENT OF ORDINARY LABOR. 23 
Fig. 2. 




When a Patient can be left. 

14. v. A patient in the first stage of labor can 
be safely left for a short time, under the following 
circumstances: a. In the ease of a primapara, if 



24 MANAGEMENT OF ORDINARY LABOR. 

the presentation be natural, and the os uteri not 
yet dilated, to the size of a crown-piece. b. In the 
case of a multipara, if the pains be few and weak, 
the presentation natural, and the os uteri not yet 
dilated to the size of a shilling, c. In any case, if 
there have been very few pains before your arrival, 
and none for at least an hour afterwards. 

a and h. Dr. Gooch gives the following judicious advice ; 
"The propriety of absenting yourself from a patient who 
is in labor will depend upon many circumstances, but 
principally upon whether or not it is a first labor. If it 
is a first labor, provided you can be within call, you may 
visit your other patients, return, ascertain the state of the 
labor, and perhaps go out again, etc. This you may do 
until the os uteri is dilated to the size of a crown-piece ; 
a process which will occupy about two-thirds of the time 
of labor; afterwards no prudent man would leave his 
patient until the labor is over. But if it is not the first 
child, the progress of the labor is very different ; the pa- 
tient has slight pains, occurring about every ten or fifteen 
minutes, just sufficient to remind her that she is in labor : 
the accoucheur is generally apprised of this state of things, 
in order that he may be in the way. On being sent for, 
after a notice of this kind, you will find that these trifling 
pains have been sufficient, perhaps, completely to dilate 
the os uteri. The pains now become stronger, and the 
membranes more distended — presently they are ruptured 
— gush goes the liquor amnii ; and if your arrival has not 
been pretty expeditious, you may be greeted on entering 
the room with the squalling of the child under the bed- 
clothes. If I am called to a labor which is not the first, 
and find the pains regular though slight, however trifling 
may be the dilatation of the os uteri, I am exceedingly 
shy of leaving my patient." 

c. If the pains have ceased in consequence of the pa- 
tient's nervousness at your sudden appearance, you will, 
by waiting an hour, have allowed ample time for the effects 
of this feeling to wear off. 



MANAGEMENT OF ORDINARY LABOR. 25 

Prognosis. 

15. After the examination has been made, the 
patient will probably ask whether all is right, and 
how long it will be before the labor is over. The 
first of these questions may be answered in the 
affirmative, if the head presents and the passages are 
in proper condition (see 10) ; but to the second you 
can only reply that it is impossible to tell with cer- 
taint}', because the duration of the labor will depend 
upon the strength and frequency of the pains, and 
other circumstances which are beyond calculation. 

Any attempt to foretell the exact duration, especially 
of a first labor, would be very likely to end in the expo- 
sure of the false prophet, and in the disappointment of the 
patient. 

[It is well especially for the student or the young phy- 
sician to bear this suggestion in mind. Never 'promise 
wlien the child vj ill probably be born.] 

Progress. 

16. When the presentation has been made out, 
the progress of the labor is to be ascertained by sub- 
sequent examinations ; but the fewer that are made 
for this purpose, during the first stage, the better. 

Frequent examinations during the first stage cause much 
discomfort, and tend to render the parts dry and irritable. 

[In the first stage frequent examinations are simply use- 
less.] 

It is difficult to lay down any precise rule as to the fre- 
quency of examinations; they should in general be made 
more frequently when the labor is rapid than when it is 
slow, but never, perhaps, oftener than once in half an hour 
during the first stage. 

3 



2G MANAGEMENT OF ORDINARY LABOR. 

Position during First Stage. 

17. It is not necessary, during the first stage, 
to keep the patient on the bed. On the contrary, 
the pains will be more effectual when she is in the 
erect posture, either sitting, standing, or walking. 

The question of position at this time is one which may 
safely be left to the patient, who may be allowed to con- 
sult her own ease and convenience. 

If, however, the pains become feeble upon lying down, 
she should be encouraged to get up occasionally and walk 
about the room. 

[It is well for the patient to keep from the bed as long 
as possible during the first stage, as under the most favor- 
able circumstances her condition is most wearisome.] 

Propriety of Occasional Absence from the Boom. 

18. The pressure upon the bladder and rectum 
during labor is apt to cause frequent desires to 
pass water and to go to stool ; you should there- 
fore retire, when you can, into another room, and 
thus relieve your patient from the restraint occa- 
sioned by 3 r our constant presence. 

It often happens that amongst the poorest class there 
is no second room into which the accoucheur can retire ; 
but when, unfortunately, such is the case, the force of habit 
has probably done much to blunt any feelings of modesty. 

Diet during Labor. 

19. During the active progress of labor the pa- 
tient's diet should be very simple. In an ordinary 
case some tea or gruel, with or without some toast 
or bread, will be sufficient. 



MANAGEMENT OF ORDINARY LABOR. 27 

The process of labor interferes with that of digestion, 
and therefore a full meal is to be avoided. 

[Oftentimes a simple article of diet affords great relief 
to the patient.] 

Signs of Second Stage. 

20. The second stage of labor commences with 
the full dilatation of the os uteri, and terminates 
with the birth of the child. It is occupied in the 
expulsion of the child, a process which is effected 
by the contractions of the uterus, aided by the 
voluntary muscles, especially those of the abdo- 
minal parietes and the diaphragm. The pains are 
of a peculiar, forcing character, and cause the 
woman to hold her breath, to fix her limbs, and to 
bear down with all her might. The low complaints 
of the first stage commonly give place to a loud 
outcry, both before and after each pain. 

Position during Second Stage. 

21. During the second stage the patient should 
be kept upon the bed, lying upon her left side. 
The part of the bed upon which she rests should 
previously be "guarded," as it is termed, by cover- 
ing it with a piece of oil-cloth, or sheet India- 
rubber, so as to protect it from the discharges, etc. 
Amongst the poorer classes it is customary to 
turn up the lower half of the bed, so as to uncover 
the sacking, upon which a folded sheet, blanket, or 
piece of carpet is then placed. 

[In this country probably the most common position is 



28 MANAGEMENT OF ORDINARY LABOR. 

upon the back. The left side seems much more delicate 
and desirable for the patient.] 

State of Uterus, Vagina, etc., during Second Stage. 

22. Vaginal examinations may be made more fre- 
quently during the second stage than previously. 
The os uteri is now fully dilated, so that the uterus 
Fig. 3. 




Fig. 3 (taken from Dr. Tyler Smith's Manual) represents the 
uterus and parturient canal in a state of full dilatation. 



MANAGEMENT OP ORDINARY LABOR. 29 

and vagina form one continuous canal. (Fig. 3.) 
At this period the membranes usually rupture, and 
the waters escape with a gush. 

Vaginal examinations occasion much less annoyance 
and irritation during the second stage, because the soft 
parts are well relaxed, and bathed freely, both by liquor 
amnii and a copious mucous secretion. 

The quantity of liquor amnii is very variable : some- 
times it is so little that its escape is scarcely apparent ; 
at other times it is sufficiently great to deluge the bed and 
to pour down on the floor. 

Diagnosis of Presentation. 

23. As soon as the membranes have ruptured, 
the exact position of the head should, if possible, 
be ascertained. The hairy scalp will now be felt 
distinctly, either loose and wrinkled, or puffy and 
oedematous; in an ordinary case the posterior 
superior part of the right parietal bone presents ; 
the occiput of the child is towards the left aceta- 
bulum of the mother ; the sagittal suture runs 
obliquely backwards, and from left to right, and 
divides the vertex unequally into two parts, of 
which the anterior is the largest and lowest ; it 
commences in front with the triangular space of 
the posterior fontanelle, and terminates behind 
with the quadrangular anterior fontanelle, which 
is opposite the right sacro-iliac synchondrosis, and 
so high as to be almost out of reach. (Fig. 4.) 

The state of the scalp will much depend upon the 
amount of pressure to which the head is subjected. If 
the labor be quick and easy, the scalp will be likely to be 

3* 



30 MANAGEMENT OF ORDINARY LABOR. 
Fig. 4. 




loose and wrinkled; if it be slow and difficult, especially 
if it be a first labor, the presenting part will become tense 
and cedematous, forming what is called the "caput succe- 
daneum." 

Descent of the Head. 

24. As the second stage advances, the child's 
head is felt to press down more and more into the 
cavity of the pelvis with each pain, and to recede 
somewhat afterwards. Still, each pain gains upon 
the advance made by its predecessor, and the head 



MANAGEMENT OF ORDINARY LABOR. 31 

gradually fills the hollow of the sacrum, until at 
last it occupies the outlet of the pelvis, and presses 
on the perineum. (Fig. 5.) 
Fig. 5. 




- ■ ■■ 



Management during the Pains. 
25. During the pains of the second stage, the 
woman should be encouraged to second the uterine 
efforts by her own exertions; you maj^, therefore, 
direct her to hold her breath, to grasp a towel, 
which is usually fastened round one of the bed- 
posts for that purpose, and at the same time to 
press firmly with her feet against the nearest bed- 
post or the footboard. 



32 MANAGEMENT OF ORDINARY LABOR. 

When the extremities are thus fixed, the muscles of the 
thorax and abdomen will act more advantageously. 

Nurses are in the habit of making firm pressure upon 
the lower part of the woman's back during each pain, and 
much relief is often thus afforded. 

Passage of Head through Outlet. 

26. As the head is passing through the outlet of 
the pelvis, it loses its former oblique position, and 
makes a slight turn, so as to bring the occiput 
beneath the arch of the pubis, and the face oppo- 
site the sacrum. At the same time, whilst the oc- 
ciput is comparatively fixed, the chin becomes 
separated from the sternum ; the face descending 

Fig. 6. 




MANAGEMENT OP ORDINARY LABOR. 33 

and describing a curve in conformity with the hol- 
low of the sacrum. The perineum, now greatly 
distended, and much reduced in thickness, covers 
the head very closely; the anus is also dilated, 
and its mucous membrane more or less protruded. 
(Fig. 6.) 

By the turn just mentioned, which is called the Move- 
ment of Rotation, the antero-posterior, or long diameters, 
of the head and pelvic outlet are brought into correspond- 
ence. 

By the second movement, which is termed Extension, 
the axes of the head, or occipito-mental diameter, assume 
the same direction as the axes of the outlet of the pelvis. 

Any feces, which may be contained in the lower part of 
the rectum, are mechanically expelled by the pressure of 
the head. This is one of the many inconveniences which 
may result from a loaded state of the rectum. 

Support of Perineum. 

21. It is generally advised that the distended 
perineum should be supported. This is usually 
effected by laying the palm of one hand (previously 
covered by a napkin) flat upon the perineum, with 
the wrist toward the coccyx, and the tips of the 
fingers forwards, and making pressure upon the 
part, in such a manner as to give the head a proper 
direction forwards, beneath the pubic arch. 1 

1 The author, being thoroughly convinced of its inutility, 
has for many years abandoned the practice of supporting the 
perineum. He would, however, advise the student, before 
doing the same, to give the practice a fair trial in a certain 
number of cases, so as to be able to form his own conclu- 



34 MANAGEMENT OF ORDINARY LABOR. 

The left hand is usually preferred for the support of the 
perineum, because the right is then free for any other 
manipulations which may be required. 

[It is not unfrequent that the patient at this juncture 
refuses to aid nature by bearing down, on account of the 
rectum being distended with feces (she dreading an evacu- 
ation). I have often known labor to be thus retarded no 
little. Inquiry should be made, and the patient directed 
to bear down, even if an evacuation of the bowels takes 
place.] 

Expulsion of Head. 

28. After a variable time, the resistance of the 
perineum is overcome, and the head, propelled by- 
two or three long and severe pains, escapes from 
the vulva. As soon as it is expelled, it resumes 
its former oblique position, so that the face looks 
upwards and backwards towards the right hip of 
the mother. 

The dilatation of the perineum, which in multipara? may 
be effected in two or three pains, may occasionally in pri- 
miparae occupy a period of several hours. Young accou- 
cheurs should, therefore, be cautious not to promise a 
speedy termination under such circumstances. 

The vertex and back of the head escape first, whilst the 
border of perineum glides successively over the anterior 
fontanelle, the forehead, and face. 

The movement of rotation, which is again performed by 
the head after its expulsion, is termed Restitution [Ex- 
ternal Rotation] . 



sions respecting its utility. Those who wish to see a full 
and clear statement of all the reasons that may be adduced 
against the practice of supporting the perineum, will do 
well to consult a little work on this subject by Dr. Graily 
Hewitt. 



MANAGEMENT OF ORDINARY LABOR. 35 

During the latter part of the second stage, the accou- 
cheur should remain sitting at the bedside, making fre- 
quent examinations, and noting carefully the exact course 
and progress of the head. 

Interval after Birth of the Head. 

29. In most cases a short interval elapses after 
the birth of the head, before the uterus resumes 
its action. During this time the child, if vigorous, 
ma}^ breathe, or even cry ; but more frequently it 
is unable to do either, until the body is born and 
the chest set at liberty. 

When the labor is rapid and the pains very powerful, 
the head and body are not unfrequently expelled by the 
same pain. 

30. Whilst waiting for the expulsion of the body, 
you may support the head of the child with your 
hand, and remove with your fingers any mucus or 
portions of membrane which may clog the mouth 
or fauces. You may also see that everything is 
ready for the child, and especially that a pair of 
scissors and a skein or two of stout thread are at 
hand, for the purpose of tying and dividing the 
cord. 

The accoucheur should wait patiently for the uterine 
contractions, and on no account attempt to hasten the 
delivery by pulling at the child's neck and shoulders — a 
practice much in favor with old nurses, but very mis- 
chievous, because it is likely to leave the uterus uncon- 
tracted, and thus to occasion hemorrhage. (For exception 
to this rule, see 49, Part II.) 



36 MANAGEMENT OF ORDINARY LABOR. 

Expulsion of Body. 

31. After the birth of the head, the uterus speedily 
renews its efforts, and expels the rest of the body. 
Whilst the shoulders are clearing the pelvic outlet, 
a movement of rotation, similar to that performed 
by the head, causes the right shoulder to pass 
beneath the pubic arch, and the left in front of the 
perineum. 

When to separate the Child. 

32. A strong, healthy child, as soon as it is born, 
will begin to breathe freely, and in most cases to 
cry vigorously. As soon as it Jias thus given 
satisfactory proof of its respiratory power, you 
may at once proceed to separate it from its mother 
by tying and dividing tfie umbilical cord. 

Ligature and Division of Cord. 

33. Having uncovered the child, so as to see 
what you are about, place a ligature, consisting 
of three or four pieces of stout thread, around the 
cord, about three fingers' breadth from the navel, 
and tie it tightly with a firm double knot; then 
place another similar ligature about an inch further 
from the navel, and divide the cord between the 
two with a pair of scissors. You then give the 
child to the nurse, who wraps it up in a piece of 
flannel called a "receiver, 77 and carries it off to 
the fireside to be washed and dressed. 



MANAGEMENT OF ORDINARY LABOR. 3t 

As soon as the child is born, the accoucheur should see 
that the air has free access to its face, and that its mouth 
and nose are not covered by bedclothes, etc. 

In uncovering the child, the clothes should be tucked 
in round the mother, so as to avoid any exposure of her 
person. 

If the accoucheur divide the cord carelessly beneath 
the bedclothes, without seeing what he is about, he may 
amputate, at the same time, portions of the child's fingers, 
toes, or even penis, as in cases related by Denman, Merri- 
man. and others. 

The threads of which the ligatures consist should, before 
being used, be united together by a knot at each end. The 
ligature nearest to the umbilicus is necessary to prevent 
the child from bleeding to death by hemorrhage from the 
divided umbilical vessels. The other ligature is not abso- 
lutely necessary, but is used chiefly for the sake of clean- 
liness, to prevent the blood contained in the rest of the 
cord from spurting out upon the bed or the clothes of the 
accoucheur. 

Before the child is given to the nurse, the portion of 
cord attached to it should be examined, to ascertain that 
the ligature remains firm, and that there is no oozing of 
blood from the umbilical vessels. 

As soon as the child is born, the mother may be informed 
as to its sex; and if the child be healthy and well formed, 
she may be satisfied upon these points also ; but if there 
be any defect or malformation, she should not be told of 
it too soon or abruptly. 

Third Stage of Labor. 

34. The third stage of labor is occupied in the 
expulsion of the after-birth. The birth of the 
child is generally followed by a short interval of 
repose, after which three or four pains set in, 
which are frequently accompanied with some dis- 
charge of blood, and resemble those of the first 
stage in character. By means of these contrac- 

4: 



38 MANAGEMENT OF ORDINARY LABOR. 

tions the uterus casts off the after-birth, sometimes 
completely beyond the vulva, but more often into 
the upper part of the vagina. 

The period of repose immediately following the birth of 
the child is generally free from pain, and is a delightful 
contrast to the preceding suffering. 

It occasionally happens, when uterine action is very 
energetic, that the child and placenta are expelled together 
by the same pain. From the flow of blood which accom- 
panies them, the pains of the third stage have been called 
the '' dolores cruenti." The blood escapes from the venous 
orifices which have been laid open by the separation of 
the placenta from the inner surface of the uterus. In some 
cases, however, there is apparently no escape whatever. 
The quantity of blood which escapes with the placenta is 
very variable; it may be as little as a tablespoonful, or as 
much as a pint without producing any material effect on 
the patient ; if it exceeds the latter quantity, it will be 
likely to produce a marked constitutional effect, as indi- 
cated by the pulse, etc. ; the case then becomes one of 
post-partum hemorrhage, and is to be treated accordingly. 
(See 55, Part II.) 

Necessity of making Abdominal Examination in 
Third Stage. 

35. As soon as you have given the child to the 
nurse, you should make it an invariable rule to 
place your hand upon the patient's abdomen, for 
the purpose of examining the uterus. In most 
cases it will be distinctly felt reaching as high as 
the umbilicus, and becoming perceptibly harder, 
so that its limits can be easily defined. When it 
is in this state, it is beginning to contract, but has 
not yet expelled the placenta. On making an ordi- 



MANAGEMENT OF ORDINARY LABOR. 39 

nary vaginal examination, } t ou can feel the cord 
only, but no portion of the placenta. 

By means of an abdominal examination, you can satisfy 
yourself, from the greatly reduced bulk of the uterus, not 
only that that organ is contracting upon the placenta, but 
that it does not contain a second child. (See 38, Part II.) 

Duration of Third Stage. 

36. The average duration of the third stage, 
reckoning from the birth of the child to the ex- 
pulsion of the after-birth, is about a quarter of an 
hour. During this time } r ou should sit by the 
bedside, occasionally examining the abdomen, and 
waiting patiently until the placenta is detached by 
the natural efforts ; but you should on no account 
attempt to hasten that process by pulling at the funis. 

The time occupied by the third stage is exceedingly 
variable : sometimes the placenta follows immediately, or 
in five minutes after the birth of the child; at other times 
it is not expelled until twenty minutes, half an hour, or 
even more, have elapsed. "When it remains more than an 
hour in the uterus, the case may be considered as one 
of retained placenta, and treated accordingly. [As a 
general rule, all circumstances being favorable, the phy- 
sician may remove the placenta if it is not expelled in 
half an hour.] (See 31, Part III.) 

Danger of Forcibly Detaching Placenta. 

Traction of the cord when the placenta is still attached, 
and especially when the uterus is uncontracted, may pro- 
duce the most disastrous consequences. It may cause — 
1. Copious hemorrhage from partial detachment of the 
placenta. 2. Inversion of the uterus. 3. Separation of 
the cord from the placenta. 4. Irregular or hour-glass 
contraction of the uterus. 



40 MANAGEMENT OF ORDINARY LABOR. 

How to Ascertain if Placenta is Detached. 

3T. In most cases, the placenta, after being de- 
tached and expelled from the uterine cavity, is 
found resting on the os tincae, or in the upper part 
of the vagina. You know that it is in this situa- 
tion, and may at once proceed to remove it, if, in 
making an ordinary vaginal examination, you can 
feel with your finger, not only the insertion of the 
cord, but also a considerable portion of the body 
of the placenta. 

If these cases are left to nature, the placenta may re- 
main several hours before the vagina has regained suffi- 
cient contractility to expel it. 

In general it is enough to be able to feel the insertion 
of the cord in order to be assured that the placenta is 
detached, but it is not always so ; because in what are 
called " battledore" placentae, the cord may be inserted 
into the lower edge of the placenta, and this portion may 
be readily reached, although the chief part of the organ 
is still attached to the uterus. 

How to Remove a Detached Placenta. 

38. To remove the placenta from the vagina, 
pass the fore and middle fingers of your left hand 
up to the insertion of the cord, and using them as 
a pulley, make steady traction upon the cord with 
the right hand — first in the direction of the inlet, 
and then of the outlet of the pelvis. The process 
will be much facilitated if you can hook down the 
edge or some portion of the placenta with the two 
fingers of the left hand. 



MANAGEMENT OP ORDINARY LABOR. 41 

To prevent the cord from slipping, it should be grasped 
with a napkin, or a coil of it twisted round the fingers of 
the right hand. By meaus of the fingers of the left hand 
you can readily feel if the cord is beginning to give way 
near its insertion. Should this be the case, you must at 
once desist from further traction upon it, and endeavor 
instead to draw down the placenta itself by the fingers of 
the left hand. 

["Such a placenta, buttoned within the orifice, should 
be dexterously unbuttoned, by bringing its edge to the 
buttonhole, as you would do with your coat-button."] 

How to Remove Membranes. 

39. In all cases, as soon as the placenta is be- 
yond the os externum, it should be turned round 
and round several times before being taken away. 
By this means the membranes, trailing behind it, 
are twisted into a rope, in which form they are 
much less likely to be torn, and are more readily 
withdrawn from the vagina. 

Any portion of membranes or clots, which may remain 
behind after the placenta, are to be also taken away. 

The placenta, when removed, is to be put into a chamber 
utensil, which should be at hand to receive it. It is after- 
wards taken away by the nurse and burnt, in accordance 
with a popular custom of long standing. 

State of Uterus after Expulsion of Placenta. 

40. As soon as the placenta has come away, you 
should again make an abdominal examination. If 
the uterus be properly contracted, you will feel it 
through the parietes, somewhere between the um- 
bilicus and pubis, as a hard, round mass, about 
the size and firmness of a child's head at birth. 

4* 



42 MANAGEMENT OF ORDINARY LABOR. 

Nature guards against hemorrhage from the open venous 
sinuses by contraction of the uterine fibres. By this means 
each bleeding vessel is secured as effectually as by a liga- 
ture. No medical man should feel satisfied in leaving his 
patient until the uterus has contracted properly. 

The uterus is seldom found to be quite in the middle 
line, but is more often inclined to one side, especially to 
the right. 

Rigors after Labor — their Treatment. 

41. The heat and perspiration produced by the 
violent exertions of the second stage are likely to 
be followed by chilliness when the labor is over. 
You may, therefore, remove the soiled sheet from 
beneath the patient, and substitute a w T arm, dry 
napkin ; and also apply to the external genitals a 
similar napkin, which the nurse usually keeps in 
readiness for the purpose. You may likewise direct 
the nurse to throw an extra blanket over her, and 
to give her some warm drink, such as tea or gruel. 

Nurses are very fond of adding some spirits to the tea 
or gruel ; but, as a general rule, such stimulants should be 
forbidden, unless the patient appear exhausted, when it 
will be a good plan to give an egg beaten up with a tea- 
spoonful or two of brandy. As the ordinary manipula- 
tions of labor are now concluded, the medical attendant 
is at liberty to leave the bedside for a short time to wash 
his hands, etc., but he should not be long away from his 
patient. 

Hoio to Wrap up the Cord, 

42. Whilst the nurse is dressing the child, 3^011 
may examine the remnant of cord attached to the 
abdomen. For the sake of cleanliness, it is usually 



MANAGEMENT OF ORDINARY LABOR. 43 

passed through a hole in the centre of a square 
piece of soft linen rag, in which it is enveloped, 
and then turned up on the abdomen. To keep it 
in place, a broad piece of flannel is passed round 
the child's body and secured by stitches. The por- 
tion of cord withers, and generally drops off about 
the end of a week. 

[Generally this occurs from the fourth to the sixth day, 
and sometimes during the sloughing there is emitted a 
fetid odor, alarming nurse and mother. It is right to ex- 
plain the cause.] 

Nurses have a prejudice in favor of scorched rag, which 
they use under the idea that it promotes in some manner 
the cicatrization of the umbilicus after the separation of 
the cord. 

Abdominal Bandage. 

43. A broad bandage should be applied round 
the abdomen, in order to support that part, and 
maintain uterine contraction. The bandage should 
consist of a piece of strong calico about four or 
five feet long, and twelve or fourteen inches wide. 
[The word calico has a different meaning in the 
United States from that in England. Here it 
signifies "printed cotton cloth having different 
colors." The common material used for a band- 
age in our country — and it is the best — is un- 
bleached muslin, heavy and strong.] It should be 
drawn firmly round the abdomen, so as to cover 
it completely, from, the ensiform cartilage to the 
pubis. The ends of the bandage should then be 
secured by three or four strong pins. \_A simple 



44 MANAGEMENT OF ORDINARY LABOR. 

but an important point. It will always be well for 
the physician to have with him a few large ^ strong 
pins.] 

The abdominal bandage is usually applied by the nurse, 
or other female attendant ; but in all cases, when there is 
any doubt as to the proper contraction of the uterus, it is 
far better that the medical attendant should put on the 
bandage himself. In cases of this kind it should be put 
on much earlier ; and sometimes it is proper to do so even 
before the birth of the child. The abdominal bandage 
should be continued for at least a fortnight. 

[It will occupy but a few minutes, and it is best that the 
young physician should apply the bandage himself.] 

Necessity of Repose after Labor. 

44. The woman should be allowed to lie quiet 
for at least an hour after the birth of the child. 
At the end of this time the attendants may change 
her dress, bandage her abdomen, and place her 
comfortably in bed ; taking care, whilst so doing, 
not to raise her in the least from the recumbent 
posture. 

[If the uterus has contracted well, and the patient is 
disposed to sleep, she should be allowed to do so, and not 
disturbed.] 

Amongst the poor, women are usually confined in their 
ordinary clothes ; they have, therefore, to undergo the 
whole process of undressing afterwards. Whilst this is 
done, they ought to remain passive in the hands of their 
attendants, and should on no account be allowed to un- 
dress themselves. 

When the Patient may be left. 

45. You should not leave the patient's house for 
at least an hour after the termination of the labor. 



MANAGEMENT OF ORDINARY LABOR. 45 

During this time, yon may occasionally look at her, 
feel her pulse, examine her abdomen, etc. Before 
leaving, you should always make a point of ex- 
amining the condition of the uterus, to ascertain 
whether it remains properly contracted. [Always 
examine the cord before leaving, in order to avoid 
any risk of hemorrhage.] 

The pulse, which during the second stage was much ele- 
vated, soon after labor subsides to, or even falls below, the 
ordinary standard. Hence an unnaturally quick pulse, half 
an hour or an hour after delivery, is often an unfavorable 
symptom, and not unfrequently forebodes hemorrhage. 
(See note 53, Part II.) 

Sometimes the uterus, after contracting, again relaxes, 
and hemorrhage is the result. The accoucheur should 
therefore satisfy himself, not only that the uterus is in a 
state of contraction, but that this condition is likely to 
be permanent. 

Necessity of Rest after Delivery. 

46. The l}'ing-in chamber should be kept per- 
fectly quiet, so as to allow the patient to sleep, or 
at all events to repose for some hours after her 
fatigues. When she has thus rested, the infant 
may be put to the breast; and this ought to be 
done within twelve hours after delivery- [In cases 
where there is hemorrhagic tendency, the sooner 
the child is applied to the breast the better. There 
is that strange, hidden S3 T mpathy between the 
uterus and mammary glands, that the one responds 
to the other, as if thus commanded, and a child 
applied to the breast, by its sucking, contracts the 
uterus.] 



4G MANAGEMENT OF ORDINARY LABOR. 

The room should be darkened by drawing down the 
blinds, and to insure tranquillity as few persons as possible 
should be admitted into it. [Most rooms in which the 
lying-in woman is confined are kept too dark. The old 
theory that the light " hurts the mother and blinds the 
child" is erroneous. It is generally conceded now, at least 
in our own country, that the room should be pleasantly 
light, for the mutual benefit of mother and child.] The 
visits of gossiping friends and neighbors should be strictly 
prohibited. The room should also be well ventilated, and 
not too warm, as is often the case amongst the poor, who 
will light up a large fire, in a small close room, in the 
middle of summer. 

The late Dr. Rigby used to recommend that the child 
should be applied to the breast immediately after delivery ; 
in some cases this may be advisable, but in general it is 
better to allow the woman to rest for some time previously. 
However, it is always far preferable to apply the child to 
the breast too soon than too late. [A singularly interest- 
ing case was recently reported to me by Dr. G. W. Holmes, 
of this city, in which all means failed to contract the uterus 
in a primiparous case until the child was applied to the 
breast.] 

How often the Patient is to be Visited. 

4*7. The frequency of your visits after a labor 
must be regulated very much by circumstances. 
As a general rule, you should see your patient 
twice within the first twenty-four hours, and once 
every day during the first week; then every second, 
third, or fourth day during the following week; 
after which, if all goes on well, you may take your 
leave. 

Inquiries to be made at First Visit. 
48. Your first visit should be within tw r elve 



MANAGEMENT OF ORDINARY LABOR. 4T 

hours after delivery. After feeling your patient's 
pulse, and looking at her tongue, you may ask if 
she has had any sleep, and has been free from pain; 
if there is any sign of milk ; if there is a plentiful 
" discharge," and if she has passed water, or had 
any action of the bowels. Respecting the child, 
you may ask if it has cried or slept ; if it has been 
put to the breast ; and if it has passed water or 
stools. 

TVomen very frequently cannot sleep for some hours 
after delivery, in consequence of the occurrence of after- 
pains; these, after some hours, subside of themselves, and 
as a general rule, require no treatment. (See 59, Part 

ii.) 

The first evacuations from the child's bowels consist 
of a substance called meconium, which is of a dark- 
greenish-brown color, somewhat resembling treacle in ap- 
pearance and consistence. If there be any doubt as to 
the child's ability to pass urine or feces, an examination 
should be made to ascertain that there is no malformation, 
such as imperforate anus, urethra, etc. 

Secretion of Milk. 

49. The secretion of milk commences within 
twelve hours after delivery, but is seldom fully es- 
tablished before the end of the third day. As the 
secretion becomes plentiful, the breasts harden and 
enlarge, their swelling occasioning feelings of ten- 
sion, and sometimes even sharp darting pains. 
The first milk is called colostrum ; it is of a yellow- 
ish color, and has a purgative effect upon the child. 

The colostrum is the* natural purgative of a newly-born 
infant. If a child is put to the breast sufficiently early, it 



48 MANAGEMENT OF ORDINARY LABOR. 

will require none of the castor oil, sugar and butter, etc., 
which nurses are so fond of giving for this purpose. 

Newly-born children seldom require any food in addi- 
tion to the breast. Should, however, the secretion of 
milk be scanty, or tardy in making its appearance, it may 
be necessary to give the child some food. The best ordi- 
nary substitute for the mother's milk is a mixture of two 
parts of coft'smilk with one part of water, sweetened 
with a little sugar. The child should suck this from a 
proper feeding-bottle. 

Excretion of Urine and Feces. 

50. After an ordinary labor there is seldom any 
difficulty in passing water, but the bowels rarely 
act without medicine ; on this account, if they 
have not been previously moved, it is a general 
rule to give a dose of castor oil on the morning of 
the third day; one tablespoonful is mostly suf- 
ficient, which inaj' be repeated after six hours, if 
necessary. 

It is a good plan to direct that the woman should pass 
water whilst leaning forward in bed upon her elbows and 
knees ; because this position readily allows the escape of 
any retained clots, portions of membranes, etc. [Do not 
fail to inquire of your patient, whether she has passed 
water. An overloaded and distended bladder might lead 
to most serious results. My own experience leads me to 
the belief that the use of the catheter is far preferable to 
the exertion consequent upon the position suggested 
above.] 

Lochial Discharge. 

51. The secretion of the uterus after delivery is 
called the lochia, or in common language, " the 
cleansings." It at first bears much resemblance to 



MANAGEMENT OF ORDINARY LABOR. 49 

ordinary menstrual discharge, being plentiful, of a 
red color, and peculiar odor, and frequently con- 
taining clots, shreds of membrane, etc. In a few 
days it becomes less abundant and paler in color, 
changing to brown, yellow, or green (when it is 
sometimes termed the "green waters"}, until at 
last it is clear and transparent ; it usually ceases 
by the end of the third week. 

[It is common for nurses to apply the napkin 
directly over the month of the vagina, to absorb 
the lochial discharge. The physician should dis- 
countenance this, directing the cloth to be placed 
under the perineum, never over the vulva. Such 
an application but dams up the lochial discharges 
against a uterus already excited.] 

During the first week or two after delivery, the whole of 
the decidual lining of the uterus softens, breaks up, and 
is discharged with the lochia. 

Diet after Delivery. 

52. The diet of a woman for the first three days 
&fter delivery should be chiefly farinaceous ; you 
may allow bread, milk, tea, gruel, arrowroot, sago, 
etc., with the addition in some cases of broth or 
beef-tea. On the fourth day some solid animal 
food may be given. At the end of a week, if all 
goes on well, the woman may resume her ordinary 
diet, and take in addition a little wine, beer, or 
porter. 
5 



50 MANAGEMENT OF ORDINARY LABOR. 

[The latter is not customary among American 
physicians, unless the exhausted condition of the 
patient especially demands it.] 

A light, unstimulating diet is proper, until the secretion 
of milk is fully established, and until any feverishness, 
which may accompany this process, has quite subsided. 
As the process of lactation subsequently makes a great 
demand on the powers of the system, a generous diet be- 
comes necessary. 

Exercise and General Management. 

53. During the first week after delivery, the 
woman should remain in bed, and be kept strictly 
in the recumbent position. During the second 
week, she may put on a loose dress, and lie on a 
sofa, or recline in an easy chair, taking care to 
stand or sit upright as little as possible. During 
the third week, she may sit up, leave her room, and 
walk a little about the house. If the weather be 
warm and favorable, she may go out of doors after 
the end of the third week ; but in winter it is better 
to wait until the end of the month at least. 

Displacements, such as prolapsus uteri, are very likely 
to be caused by getting up too soon after delivery; the 
frequency of such complaints amongst the poor is thus 
accounted for. Secondary hemorrhage, also, may be thus 
produced. 



PART II. 

CASES WHICH THE STUDENT MAY UNDER- 
TAKE WITHOUT ASSISTANCE. 



Cases of supposed Pregnancy. 

1. A woman sends for 3^011 who believes herself 
to be in labor, but who in reality is not pregnant. 
You may know that such is the case, and may at 
once undeceive her, if, on making a vaginal exami- 
nation, you find that there is no shortening of the 
neck, and no enlargement of the body, of the 
uterus. 

The cases which may simulate pregnancy, and even 
commencing labor, are usually those in which there is 
suppression of the menses, with enlargement of the abdo- 
men, from tumors or cysts of various kinds, accompanied 
with a want of tone and a tympanitic distension of the 
bowels. Such symptoms are most frequently met with in 
women approaching the "turn of life," or the age at which 
the menses cease. In these cases the more conclusive 
signs of pregnancy, such as the sounds of the foetal heart 
and ballottement, are of course wanting. 

In the unimpregnated state the cervix uteri forms a 
conical projection, about three-quarters of an inch or an 
inch long, into the upper part of the vagina. 

The absence of shortening in the uterine neck denotes 
either the absence of pregnancy, or, at all events, the non- 
completion of the first half of utero-gestation. 



52 CASES NOT USUALLY 

The absence of any enlargement of the body of the 
uterus denotes the absence of pregnancy. To ascertain 
this, the uterus should be poised on the fore-finger of one 
hand, whilst the other hand is pressed on the hypogastrium. 
By pressing on its neck, either behind or in front, the 
uterus may be made to swing backwards or forwards, and 
thus its weight and mobility may be estimated. By pass- 
ing the finger as high as possible round the uterine neck, 
any bulging or increased size of the body may be recog- 
nized. 

Abortion — Diagnosis. 

2. A woman, in the first four or five months of 
her pregnane}^ sends for you, because she has ex- 
perienced periodical pains, like those of the first 
stage of labor. In all probability, abortion is im- 
minent ; but 3^011 may feel sure of this, if the pains 
are followed by hemorrhage from the vagina, and 
especially if you find that they cause the os uteri 
to dilate, and the ovum to protrude through it. 

By the terra abortion is implied the expulsion of the 
fcetus before the period of its legal viability, which has 
been fixed at six months. Abortion is much more fre- 
quent during the first two months than at a more advanced 
period of pregnancy. 

Vaginal examinations, in these cases, should be made 
with much gentleness and care, lest the tendency to abor- 
tion should be thereby increased. 

Treatment of Abortion. 

3. If the pains are few, the hemorrhage little or 
none, and the os uteri not open enough to admit 
the finger, yon may hope to prevent miscarriage. 
Accordingly you enjoin perfect rest in the horizon- 



REQUIRING A CONSULTATION. 53 

tal posture, in a cool room. You then endeavor 
to check uterine action by opiates. For instance, 
you may give a draught containing ttt^xx of liq. 
opii sedat. immediately, followed every two hours 
by a mixture containing n^v of liq. opii sedat. and 
5j of infus. rosse acid, to each dose ; or you may 
give an enema of n^xx of laudanum in giss of gruel 
every hour until the pains are checked. 

When the patient is plethoric, general or local bleeding 
may be required in conjunction with opiates ; but before 
resorting to this measure, the student had better send for 
further advice. 

Treatment of Abortion — Premature Labor. 

4. If, however, the pains are frequent and in- 
creasing in severity, and especially if you can feel 
the ovum protruding, there is but little hope of 
checking the miscarriage : the case may then be 
left to nature. But as various accidents (See Part 
III., 1 and 2) may occur during and after miscar- 
riage, it requires quite as much watching as a labor 
at the full term. 

The clots which come away in the course of an abortion 
should be carefully inspected, to see if they contain the 
entire ovum, or any portions of it, such as membranes, etc. 

Miscarriages are called premature labors when they take 
place during the viability of the foetus ; that is, after the 
sixth month. They differ from abortions in being accom- 
panied by little or no hemorrhage, and bear more resem- 
blance to labors at the full term. The means recommended 
for the arrest of abortion are to be employed with a view 
to prevent premature delivery. 

[See Chapter on Abortion.] 

5* 



54 CASES NOT USUALLY 

Spurious Pains — Diagnosis. 

5. Women, towards the end of pregnancy, occa- 
sionally suffer from spurious pains, which simulate 
those of labor. They are distinguished from true 
labor-pains by their partial and irregular character; 
but principally by their being unaccompanied with 
" show," and causing no dilatation of the os uteri. 

False pains are mostly limited to the fundus uteri, and 
are felt in the abdomen chiefly, around the umbilicus ; 
whilst true pains are felt mostly in the back and thighs, 
and affect the whole uterus, but especially the os tincae. 

Spurious Pains — Treatment. 

6. Spurious pains may arise from colic caused 
by constipation, errors of diet, etc., or from rheu- 
matism of the uterus, in consequence of cold. Their 
treatment should depend very much upon their 
cause. In general, they may be checked by ape- 
rients, such as a dose of castor oil, or a warm-water 
enema followed by sedatives, as n^xx of tinct. opii, 
or gr. x of Dover's powder. 

Spurious pains should always he checked, as they tend 
to exhaust the woman, and are productive of no good ; 
nay, they may even retard labor, if it has already com- 
menced. 

[Enforce the supine position for a time. Never use 
opium until the bowels are opened.] 

Vomiting during Labor. 

7. Vomiting is a very frequent occurrence during 
labor, particularly towards the end of the first 



REQUIRING A CONSULTATION. 55 

stage. The matter ejected usually consists of 
mucus, together with any food or drink that has 
been last taken. It is by no means an unfavorable 
occurrence, and very rarely requires any treat- 
ment. 

The vomiting appears to depend on a kind of sympathy 
between the stomach and the uterus, and is mostly observed 
at the time when the os uteri is rapidly giving way to the 
dilating pains. It is a common saying amongst nurses, 
that " sick labors are safe ;" but it is far otherwise when 
vomiting comes on after a prolonged second stage, and is 
accompanied with great prostration, etc. (See Part III. 
27.) 

Retarded Labor from Loaded Rectum. 

8. Labor is sometimes retarded by a loaded rec- 
tum. In such cases an indurated cylinder is felt 
at the back of the vagina, which might be mistaken 
by an inexperienced person for a prominent sacrum. 
By a careful vaginal examination you may distin- 
guish the scybalous masses, and may partially 
displace them by pressure. The proper treatment 
is to empty the rectum by an enema of warm 
water, or, if this fail, by an enema of a pint of 
warm gruel containing §ss of ol. terebinth., and the 
same quantity of ol. ricini mixed up with the yelk 
of an e^s*. 

A loaded state of the rectum is a fertile source of spu- 
rious pains, as well as a mechanical obstacle to delivery. 
The obstacle thus presented is seldom insuperable, for the 
descending head will at last, after much pain to the patient, 
and greatly to the annoyance of the practitioner, mechani- 
cally expel the contents of the rectum. 



56 CASES NOT USUALLY 

Should the above-mentioned enema fail, it will be neces- 
sary to break up the hardened mass of feces with a wooden 
scoop, or the handle of a spoon ; and then to repeat the 
enema : but as this proceeding requires some care in man- 
ipulation, it will be more prudent first to send for further 
advice. 

Tedious First Stage. 

9. The first stage of labor is sometimes very 
tedious, from various causes, such as inefficient 
uterine action, rigidity of the soft parts, etc. ; espe- 
cially in primiparse, and, above all, in those who 
are not young. In such cases the first stage may 
last many days. In general, the only remedy is 
time and patience. The delay, although fatiguing 
to all parties, is very rarely dangerous: you should, 
therefore, do all you can to cheer your patient and 
keep up her spirits. 

The medical attendant should frequently leave the pa- 
tient's room, and, above all, should beware of making fre- 
quent examinations. He should assure her that her labor 
has barely commenced, and that there is no danger. Dr. 
Churchill's statistics abundantly prove how little danger 
attends a prolonged first stage. 

Inefficient Uterine Action — Treatment. 

10. Inefficient uterine action may arise from 
natural delicacy of constitution, or from any de- 
bilitating cause, either mental or bodily. If the 
patient be not a primipara, if she has had good 
labors previously, if the vertex present, and if, in 
short, you are sure there is no mechanical obstacle 
to delivery, you may give ergot of rye to increase 



REQUIRING A CONSULTATION. 57 

uterine action ; but you should not venture to do 
so without a consultation, provided any of these 
conditions present. 

The ergot may be given in three half-drachm doses at 
intervals of about a quarter of an hour. The bruised or 
powdered grains will, if good, answer best. One drachm 
and a half of the powder should be mixed with half a 
pint of hot water, and allowed to simmer a few minutes 
over the fire. One-third of this decoction should be given 
(grounds and all) every quarter of an hour. Or, instead 
of the powder, the Extract. Ergotse Liquid, may be given 
in gss doses. [Occasionally ergot fails to have any effect 
over the uterus, but this is rare. Dr. Meigs extracts a 
case from Dr. Lee's Clinical Midwifery, in which the pa- 
tient took gvij in sixteen days, without sensible effect 
upon the uterus. On the other hand, very small doses may 
produce violent uterine contraction. These contractions 
are not like those of natural labor. They are of greater 
strength and longer duration, "like a number of violent 
labor-pains continued into one another without intervals."] 

During the progress of a tedious labor, when there is 
much debility, beef-tea and wine should be given fre- 
quently. 

Tedious Labor from want of Sleep — Treatment. 

11. Inefficient uterine action not unfrequently 
arises from want of sleep, and restlessness caused 
by a prolonged first stage, and thus tends still 
further to produce delay. In such cases the ad- 
ministration of a sedative is attended with the 
best results. After a sound sleep, the patient 
awakes refreshed, and the pains set in with renewed 
vigor. 

Twenty minims of Tinct. Opii or 20 grains of Hydrate of 
Chloral may be given and repeated after three hours, if 



58 CASES NOT USUALLY 

necessary. As a hypnotic, Hydrate of Chloral is, in some 
respects, superior to opium. It may be conveniently given 
as follows : H Chloral. Hydrat. gr. xl. ; Syrupi Aurantii 
3ij. ; Aquam adgiv. M., sumat dimidiam part, statum. 

Rigid Os Uteri — Treatment. 

12. Rigidity of the os uteri is a frequent cause 
of delay in the first stage of labor. It is most 
usual in primparse, and chiefly in those who have 
passed the age of thirty-five or forty. The rigid 
os will generally give way and the labor termi- 
nate favorably, provided sufficient time be given. 
Should the woman be plethoric, bleeding, opium, 
tartar emetic, chloroform, etc., may be resorted to ; 
but before employing such measures you had better 
request further advice. 

[Ether or chloroform, administered simply to 
that extent that will ease and tranquillize the 
patient, is by far the best remedy for rigidity of 
os uteri.] 

Premature Rupture of Membranes. 

13. Premature rupture of the membranes may 
be a cause of a tedious first stage ; the os uteri 
being dilated much more slowly and painfully by 
the child's head than by the bag of the-membranes. 
This is most likely to happen in first labors. In 
such cases all that is required is time and patience. 
If there be unusual difficulty, the remedies for an 
undilatable os uteri are indicated. 



REQUIRING A CONSULTATION. 59 

(Edematous Os Uteri. 

It occasionally happens in such cases that the anterior 
lip of the os uteri becomes swollen and cedematous from 
pressure between the head and the os pubis. This state 
of thiugs will nearly always rectify itself in time; but if 
it should not, the anterior lip may, in the interval of a 
pain, be raised by the finger above the crown of the head, 
and kept there during two or three pains, until it is fully 
retracted. 

Unusual Toughness of Membranes. 

14. Labor is sometimes retarded by unusual 
toughness of the membranes. Long after the os 
uteri is fully- dilated, the membranes may remain 
entire, and the pains, in consequence, not put on 
the forcing character of the second stage. To 
remedy this, you should rupture the membranes 
by pressing firmly upon them with the forefinger, 
when they are rendered tense by a pain. Should 
this fail, you may notch the finger-nail like a saw, 
and rub it to and fro on the bag of the membranes 
until it gives way. 

[Both of these means will sometimes fail to 
rupture the membranes. If so, you should — in the 
absence of a pain — take up a portion of the flaccid 
membranes between the forefinger and thumb, and 
as the contraction of the uterus takes place, slightly 
twist the fold, and you will thus succeed.] 

The membranes should on no account be ruptured until 
it is quite certain they have answered their purpose by 
completely dilating the os uteri. 



60 CASES NOT USUALLY 

Anterior Obliquity of Uterus. 

15. In some multipara, the abdominal parietes 
may be so relaxed as to allow the fundus uteri to 
fail very much forwards. This anterior obliquity 
of the uterus is called in common language, " pen- 
dulous belly," and may be a cause of tedious labor. 
The os uteri is thrown so much upwards and back- 
wards towards the sacrum, as to be almost out of 
reach. The remedy is to support the belly by 
means of a broad bandage, and to keep the woman 
lying on her back during the pains. 

In addition to the anterior obliquity just described, the 
fundus uteri may be inclined to either side, constituting 
lateral obliquity. This species requires much the same • 
management as the preceding, viz., to support the abdo- 
men, and to place the patient on the opposite side to that 
towards which the fundus uteri is inclined. 

Undilatable Vagina and Perineum- — Treatment. 

16. Delay may be occasioned in the second stage 
of labor by a rigid, undilatable condition of the 
vagina and perineum. This state is peculiar to 
primiparse, especially such as are not young, and 
in these the dilatation of those parts may occupy 
several hours. The parts feel dry and tense, and 
admit the finger with difficulty. To promote their 
dilatation, you may use warm fomentations and 
inunctions, or you may direct the woman to sit 
over a pan of warm water. Should these means 



REQUIRING A CONSULTATION. 61 

fail, the remedies for an undilatable os uteri are 
indicated. (See Part II., 12.) 

Chloroform is sometimes of great use in these cases ; 
but the student should not administer it without a con- 
sultation. 

[" In all forms inflammation is apt to supervene. Hence 
watch to prevent it."] 

Presentations ivith Forehead anteriorly — 
Diagnosis. 

11. Labor may be retarded in the second stage 
by unfavorable presentations of various kinds. 
Thus, in some presentations of the vertex, the 
forehead may be in the anterior, instead of in the 
posterior semicircle of the pelvis. You may ascer- 
tain that the head is in this position, even before 
the os uteri is fully dilated or the membranes rup- 
tured, by noticing that the posterior lip of the os 
uteri is much lower in the pelvis than the anterior 
lip. (Fig. 7, 1.) After the rupture of the mem- 
branes, the posterior fontanelle will be found in 
the posterior half of the pelvis, and the anterior 
fontanelle in the anterior half, behind one or other 
groin. 

The depression of the posterior lip of the os uteri de- 
pends on the following circumstances: In ordinary labor 
the child's head is, at the commencement of the labor, 
flexed upon its body ; but during its progress the head 
becomes still more flexed by the chin approaching still 
nearer to the sternum. The result of this is, that the 
posterior half of the child's head is much lower than the 
anterior. Consequently, in the occipito-anterior presenta- 



CASES NOT USUALLY 



tions, the occiput, being in front, presses upon the anterior 
lip of the os uteri, and depresses it much below the level 

Fig. 7. 




1. Occipito- posterior Presentation, 




2. Occipito- anterior Presentation. 



REQUIRING A CONSULTATION. 63 

of the posterior lip. (Fig. 7, 2.) But in occipito-posterior 
presentations the reverse takes place ; the occiput, being 
behind, depresses the posterior below the anterior lip. 
(Fig. 7, 1.) Hence the shape and position of the os, on 
making a vaginal examination, appear to be very different 
from that which we ordinarily find. In ordinary cases 
the finger passes but a slight distance into the angle, or 
cul-de-sac, formed by the junction of the vagina and the 
anterior lip of the os (see Fig. 2). But in the occipito- 
posterior positions the finger passes high up behind the 
symphysis pubis into the cul-de-sac just mentioned, which 
in this case forms an acute angle, as in the first it formed 
an obtuse angle. At the same time the posterior lip, and 
even the entire os, is unusually low in the pelvis. 1 

Presentations of Forehead anteriorly — How 
altered by Nature. 

18. Many of these cases will be converted by the 
natural efforts into ordinary vertex presentation. 
Thus, as the head descends into the pelvis, it will 
perform a movement of rotation, the forehead 
moving backwards from the acetabulum to the 
sacro-iliac synchondrosis on one side, and the occi- 
put moving forwards in a similar way on the oppo- 
site. This movement may be effected artificially, 
provided the second stage be not too far advanced. 

Dr. Ramsbotham thus describes the mode in which such 
presentations should be altered : " Presuming that, after a 
number of tolerably strong expulsive pains, no advance 
takes place in the situation of the head, it will then be 
proper to embrace the cranium between the first three 
fingers and the thumb of one or other hand, and to give 
the face an inclination to the right or left ilium, accord- 

1 See paper by the author on Varieties of Cranial Presenta- 
tion, British Medical Journal, Feb. 4th, 1852. 



64 CASES NOT USUALLY 

ing as its original direction was to the right or left groin ; 
and this attempt must be made in the absence of uterine 
contraction, and before the head has become locked in the 
pelvic cavity; for if it be delayed till a state of impac- 
tion has occurred, the mal-position cannot be remedied by 
the power of the hand alone, and instruments will most 
likely be required in order to finish the delivery." 

The student will do well not to take upon himself the 
responsibility of altering one of these presentations, be- 
cause such a proceeding requires an amount of tact and 
skill which can only be acquired by experience. 

Labor where Forehead continues in Anterior 
Semicircle. 

19. But, in many instances, the turn above de- 
scribed does not take place, and the forehead con- 
tinues in the anterior semicircle. The labor is 
thus rendered more tedious, but is nevertheless, 
with but few exceptions, accomplished by the 
natural efforts. The head, as it presses clown into 
the cavity of the pelvis, becomes more and more 
flexed on the body, until at last the anterior fon- 
tanelle is placed beneath the pubic arch, and the 
occiput presses on the perineum, causing more dis- 
tension of that part than usual. Finally, the occi- 
put is expelled first, and then the forehead and 
face. (Pig. 8.) 

In ordinary labor, as the head passes through the outlet 
of the pelvis, the chin leaves the chest, and the head is 
extended upon the body; in occipito-anterior presenta- 
tions the reverse takes place, and hence the long axes of 
the child's head and body are not so well adapted to the 
axes of the pelvis ; but there is reason to believe that the 
difficulties of such presentations have been much over- 
rated, upon grounds which are more theoretical than 



REQUIRING A CONSULTATION. 



65 



practical. Thus it has been stated, that, in consequence 
of its shape being more square, the forehead does not 

Fig. 8. 




adapt itself so well as the occiput to the arch of the pubis, 
as the head clears the outlet of the pelvis : without con- 
sidering how materially that shape may be altered by the 
overlapping of the frontal bones at their suture. It has 
been likewise stated that, at the moment of expulsion, the 
perineum is put much more on the stretch, and is in more 
danger of rupture, because the occipito-frontal diameter 
of the child's head (which, in the occipitoanterior pre- 
sentation, is in relation with the antero-posterior diameter 
of the pelvic outlet) is much longer than the trachelo- 
bregmatic, which is in apposition with it in ordinary cases. 
Here, again, no account is taken of the great capability 
which the occipito-frontal diameter has of being lessened 
by the overlapping of the parietal and frontal bones at 
6* 



G6 



CASES NOT USUALLY 



the coronal suture. In fact, in most instances of occipito- 
posterior presentations, this shortening actually takes 
place to a great extent, so that the head is at first so 
much altered in shape as to be nearly round ; whereas in 
the occipitoanterior presentations the head becomes ma- 
terially lengthened, especially when the labor is at all 
protracted. 

Should the head be arrested in the cavity of the pelvis 
for some hours, or should there be unusual difficulty in 
any of these cases, the student ought to send for assist- 
ance, as the forceps will probably be required. 

Face Presentations — Mechanism. 
20. Face presentations occur about once in 231 
Fig. 9. 




REQUIRING A CONSULTATION. 67 

cases. 1 The right cheek-bone ordinarily presents ; 
the forehead being towards the left acetabulum, 
and the chin towards the right sacro-iliac synchon- 
drosis. (See Part III., Fig. 15.) In all face pre- 
sentations, as the head passes out of the pelvis, 
the chin makes a turn from behind forwards, so as 
to emerge bemeath the arch of the pubis, whilst 
the forehead and vertex sweep over the perineum. 
(Fig. 9.) 

The ordinary face presentation is in fact nothing more 
than the ordinary presentation of the vertex, with the 
head extended instead of flexed upon the body. 

Diagnosis of Face Presentations. 

21. The face can scarcely be confounded with 
any other presentation except the breech, and that 
only when the parts are swollen from protracted 
labor. You may recognize the face, before the 
membranes are ruptured, by the hard prominences 
of the molar bone, forehead, bridge of the nose, 
and rim of the orbit. After the membranes are 
ruptured, you can feel the openings of the nostrils 
and mouth, and you can also feel within the mouth 
the tongue and gums. By the presence of these 
organs you at once distinguish the mouth from the 
■anus, as well as by the absence of meconial dis- 
charges, etc. (See 24, Part II.) 

If a face presentation be suspected, the part should be 
examined with gentleness and care. Instances are related 

1 For these statistics see Dr. Churchill's "Midwifery," 



68 CASES NOT USUALLY 

in which cheeks have been flayed, and even eyes " gouged 
out," by the finger-nails of rough, awkward examiners. 

When the child is born, the face is generally much dis- 
figured ; for if the second stage be at all protracted, the 
presenting cheek and eyelids become greatly swollen and 
discolored from ecchymosis. 

Management of Face Presentations. 

22. As a general rule face presentations require 
no interference. The labor may be longer and 
more difficult than with a vertex presentation, but 
will ultimately be finished by the natural efforts. 
If the head should be arrested, or if the chin should 
not come round beneath the pubic arch, the for- 
ceps or vectis may be required. In such a case 
you should send for assistance. 

The diameters of the face are not longer than those of 
the vertex ; but the axes are not so well adapted to those 
of the pelvis, nor is the face so compressible as the vertex. 

Breech Presentations — Mechanism. 

23. The breech presents about once in 59 cases. 
The body of the child is placed obliquely in the 
pelvis, with the back either in front towards the 
right or left acetabulum, or behind, towards the 
right or left sacro-iliac synchondrosis. The child 
is expelled with one side behind the pubic arch, 
and the other in front of the perineum ; and, in 
favorable cases, the head turns so as to bring the 
face into the hollow of the sacrum. 

In its natural position the foetus in utero bears some 
resemblance in shape to an egg, the head forming the large 



REQUIRING A CONSULTATION. 



69 



and the nates the small end. On this account a presenta- 
tion of the latter at first meets with less resistance than 
one of the former. In such a case, therefore, the first 
part of the labor should on no account be hastened, but 
should rather be retarded, so as to give the soft parts 
ample time to dilate. 

In a proper breech presentation, the legs are so flexed 
upon the abdomen that the feet are at first out of reach. 

Fig. 10. 




In the most frequent position of the breech, the left 
ischium of the child presents, and corresponds to the left 
acetabulum of the mother; the belly of the child being di- 
rected forwards and to the right. (Fig. 10.) 



70 CASES NOT USUALLY 

Diagnosis of Breech Presentation. 

24. You may recognize a breech presentation 
before the membranes are ruptured, if you can dis- 
tinguish the cleft between the buttocks, and one or 
both tubera ischii, and especially if you can make 
out the pointed prominence of the coccyx in the 
centre. If you can reach high enough, you may feel 
the femur and recognize it by its great length. 
You may also be able to feel the very characteristic 
prominence of the anterior superior spinous process 
of the ilium, and to pass your finger into the angle 
between it and the femur. After the membranes 
are ruptured, you can distinguish the parts of 
generation, and meconium will escape from the 
anus. If you introduce your finger into the anus, 
you can feel the sphincter ani contracting, and the 
finger, when withdrawn, will be soiled with meco- 
nium. 

[The value of being able to diagnosticate a breech pre- 
sentation was illustrated not long ago by the following 
circumstance: A prominent medical gentleman of this 
city, in attendance upon a lady in her confinement, in 
which, by examination, he found by anus, tuber ischii, scro- 
tum and penis, there was to be born a son, notified the 
father accordingly, and of course a son was born. A few 
days after, the unlearned but delighted father sent the 
physician a check for five hundred dollars, remarking 
that any physician deserved that sum who could tell the 
sex before the birth.] 

The tuber ischii forms a hard, blunt prejection in the 
centre of the soft cushion presented by the buttock. 

In male children the scrotum occasionally becomes enor- 
mously swollen from oedema, produced by compression 



REQUIRING A CONSULTATION. Tl 

between the thighs. The tumor thus formed may prove 
very puzzling to the young accoucheur, if not previously 
aware of the circumstance. 

Cases in which no Interference is necessary. 

25. Breech cases, although more tedious than 
those where the vertex presents, are not usually 
dangerous to the mother. But there is much dan- 
ger to the child from compression of the cord by 
the head whilst passing through the pelvis. Still, 
if the patient be not a primipara, if the labor be 
rapid, and the child favorably situated (that is, 
with its back in front, and its head and arms flexed 
upon its body), such cases may terminate well 
without any kind of manual interference. 

In no instance, perhaps, is so much mischief produced 
by meddlesome midwifery as in breech presentations ; and 
yet these are the very cases in which an ignorant midwife, 
rejoiced at having something to pull at, would drag down 
the lower extremities under the idea of forwarding the 
labor. The result is, that time is not allowed for the soft 
parts to dilate. If traction be made between the pains, 
the child's arms, previously flexed across the chest, are 
carried above the head; the chin hitches upon the brim 
of the pelvis, and a favorable presentation of the head is 
thus changed into an extremely unfavorable one ; great 
delay is thereby produced, and the child's life in all proba- 
bility is sacrificed. 

Gases for Interference. 

26. In most breech presentations, some inter- 
ference is necessary, but not until the lower half of 
the body is expelled. The danger to the child 
then commences : if, therefore, the upper half do 



72 CASES NOT USUALLY 

not speedily follow, the labor must be hastened. 
As soon as you can reach the umbilicus, you may 
pull down some of the cord, in order to relax it, 
and then place the rest in the hollow of the sacrum, 
where it will be more out of the way of pressure. 
Then, wrap the child's body in flannel, grasp its 
hips firmly, and hasten its expulsion by steady 
traction during the pains. If the child's back be 
situated posteriorly, you must rotate the trunk be- 
tween the pains so as to bring that part ronnd to 
the front. 

A convulsive starting of the child's limbs will sometimes 
indicate the approach of asphyxia from pressure on the 
cord. When such a symptom is noticed, there is an urgent 
necessity for immediate delivery. In breech presentations, 
the patient's friends 1 should be informed that the child is 
not presenting rightly, and that in consequence its life 
will be in danger, but that she herself will not incur any 
additional risk, nor will there be any necessity for turning 
the child. 

How to bring down At*ms. 

21. If the arms be raised above the head, they 
must be brought down ; and it is generally easier 
to bring down the posterior arm first. For this 
purpose, pass two fingers over the shoulder from 
the back, and depress the arm obliquely downwards 
and forwards across the chest. Then bring down 
the anterior arm in a similar manner. (Pig. 11.) 

1 It is perhaps better not to inform the patient herself. 



REQUIRING A CONSULTATION. ?3 

Fig. 11. 




If attempts are made to bring down the arm in an oppo- 
site direction to that indicated, the elbow will in all proba- 
bility hitch upon the brim of the pelvis, and. the force 
being exerted at right angles with the humerus, that bone 
will almost iuevitably be fractured. 

How to bring down Head. 

28. If the face be in front, and the chin much 

raised from the chest, the position of the head must 

be changed. Pass the first two fingers of the left 

hand into the mouth, and press the chin backwards 

1 



u 



CASES NOT USUALLY 



towards the sacrum, and downwards towards the 
chest of the child (Pig. 12). Then pass two fingers 



Fig. 12. 




of the other hand behind the occiput, grasp the 
head between both hands, and extract it first down- 
wards and backwards in the axis of the brim, and 
then downwards and forwards in the axis of the 
outlet of the pelvis. If the child be in a state of 
suspended animation after birth, the proper means 



REQUIRING A CONSULTATION. 75 

for restoring it should be bad recourse to. (See 
Part II., 51 and 52.) 

"When the chin is much raised, the longest diameter of 
the head, viz., the occipito-mental, corresponds to one of 
the diameters of the pelvis. By depressing the chin we 
substitute a shorter diameter, such as the trachelo-breg- 
matic, or, at all events, the occipito-frontal. 

When the chin is towards the front of the pelvis, it is 
very likely to hitch over the pubis, and thus prevent the 
expulsion of the head. 

Should there be unusual difficulty in extracting the 
head, that object may sometimes be attained by moving 
both arms simultaneously in the direction of the dotted 
line in Figure 12. 

If the nose can be reached, it will be found that by 
placing the two fingers, one on each side of it, and depress- 
ing the upper maxilla, the head can be acted upon more 
powerfully than by passing them into the mouth. 

Presentation of Feet or Knees. 

29. Tbe inferior extremities, tbat is, tbe feet or 
knees, present about once in 105 cases. Tbe feet 
may present in two ways, either witb tbe toes 
turned backwards or forwards, tbe former being 
tbe most common. Wben tbe feet or knees present, 
they do not dilate tbe soft parts as well as tbe 
breech. Tbe first part of tbe labor is consequently 
likely to be quicker tban in a breecb presentation, 
but tbe last part more lingering. Hence tbere is a 
greater clanger to the child ; but, in otber respects, 
tbe mechanism of tbe labor is similar. 



76 CASES NOT USUALLY 

Foot Presentations — Diagnosis. 

30. The foot can scarcety be mistaken for any 
other part except the hand. If you can only reach 
the toes, you may distinguish them from the fingers 
by the following peculiarities : The toes are much 
shorter, and consequently cannot be doubled up 
like the fingers. The great toe is close to the 
others, and of the same length, whereas the thumb 
is shorter than the fingers, and widely separated 
from them. If you can reach the ankle, yon feel 
the heel and malleoli ; you also find that the foot 
is thicker than the hand, and is articulated at right 
angles with the leg, whereas the hand is in a direct 
line with the forearm. If the membranes be rup- 
tured, and especially if both feet can be felt, a 
mistake is scarcely possible. 

It is of the greatest consequence in these cases that a 
correct diagnosis should be formed before the water es- 
cape. At the same time, too much care cannot be taken 
lest the membranes be ruptured in making the necessary 
examination. 

Knee Presentations — Diagnosis. 

31. The knee bears more resemblance to the 
elbow than to any other part ; but it is larger and 
rounder than the elbow, and you can feel a depres- 
sion between the two elevations formed by the 
cond3 r les of the femur. On the contrary, you re- 
cognize the elbow by the pointed projection of the 
olecranon between the condyles of the humerus. 



REQUIRING A CONSULTATION. 17 

But all doubt is removed if you can reach the foot 
or the breech, and especially if both knees present. 

It is scarcely possible that both elbows should present 
at once, but very likely that both knees should do so. 

Management of Knee or Footling Cases. 

32. Knee or footling cases must be managed in 
the same way as breech presentations, except that 
there is still more reason for delaying the first part 
of the labor. If one foot or one knee present, you 
should not attempt to bring down the other, be- 
cause a larger dilating body is presented if you 
allow the limb to remain flexed upon the trunk. 

Compound Presentations. 

33. It sometimes happens that two different parts 
of the body present, forming what is called a com- 
pound presentation ; thus the hand may present 
with the head, the breech, or the foot. The hand 
is known by the signs enumerated above. (See 30, 
Part II.) Great care is necessary in examining ; 
for the head or breech may be pushed up, or the 
arm pulled down, through ignorance or inadvert- 
ence. 

Should the arm become completely engaged in the pel- 
vis, and should the other presenting part recede, the pre- 
sentation becomes one of the most unfavorable with which 
the accoucheur has to deal. 
7* 



78 CASES NOT USUALLY 

Management of Presentations of Hand with Head. 

34. When the hand comes down before the head, 
there is generally more room in the pelvis than 
usual, and therefore you need be in no hurry to 
interfere. When the head is fully engaged in the 
cavity of the pelvis, you may make a cautious at- 
tempt to push the hand above it. If there be any 
difficulty in doing this, you may let it remain ; for, 
in all probability, it will merely have the effect of 
somewhat retarding the labor. Should, however, 
the head become arrested, you had better send for 
assistance, as the forceps may be required. 

Presentations of the hand with the head are more fre- 
quent in premature deliveries than in labors at full term. 

Treatment of Presentations of Hand with Breech 
or Foot. 

35. When the hand presents with the breech, the 
case should be treated as an ordinary breech pre- 
sentation. If it present with the foot, the foot 
should be drawn down, so as to convert the case 
into a presentation of the inferior extremities. 

In presentations of the hand and foot the cord fre- 
quently prolapses. The safety of the child then requires 
that the labor should be terminated without delay. 

Plural Births. 

36. " Plural Births" are those in which more 
than one foetus is expelled. Twins occur about 



REQUIRING A CONSULTATION. 79 

once in 81 cases. Cases of three or more at a birth 
are exceedingly rare. Twin children are nearly 
alwaj's below the average size; they are inclosed 
in separate membranous bags ; the placentae also 
are distinct, although usually united by their 
edges. In the majority of cases the heads of both 
children present, but it is almost as common to 
find the bead of one and the breech or feet of the 
other presenting. In some rare cases there is only 
one common placenta. 

[It is estimated that in about two-thirds of the cases 
the head of each child presents, and the largest one de- 
scends first. Malpositions of the foetus are far more com- 
mon in twin cases than in single pregnancies.] 

The mortality amongst twins, and especially triplets or 
quadruplets, is greater than amongst other children, from 
the circumstance that these labors are more often prema- 
ture than others, and also that the children are smaller 
and less vigorous. 

Mechanism of Twin Labors, 

37. The delivery of the first child Is usually more 
tedious than an ordinary labor, but the delivery of 
the second is much more speedy. In most cases 
there is an interval of rest between the birth of the 
first and second child, which ma}' vary from five 
minutes to half an hour or more. The membranes 
of the second child do not rupture until after the 
birth of the first ; the two placentae are expelled 
after the birth of the second child. 

The delivery of the first child is slow, from the circum- 
stance that much power is lost, because a considerable 



80 CASES NOT USUALLY 

portion of the uterine pressure is transmitted indirectly, 
through the medium of the second child. The delivery 
of the second child is speedy, because the soft parts are 
well dilated by the passage of the first. 

The period of repose between the birth of the first and 
second child has been known to last for several hours, and 
even days. Dr. Merriman relates a case in which the 
second child was retained for six weeks. 

Diagnosis of Twins. 

38. Before labor commences there is no certain 
sign by which you can ascertain the presence of 
twins, with the exception, perhaps, of that which 
is derived from the auscultation of two distinct 
foetal hearts. After the first child is born, the 
nature of the case is obvious ; if you place your 
hand on the abdomen, the uterus feels tense, hard, 
and but a little diminished in size ; if you examine 
per vaginam, you at once distinguish the bag con- 
taining the presenting part of the second child. 

Before labor the size of the abdomen is a very fallacious 
sign of the presence of twins, for it may depend on other 
causes, such as excess of liquor amnii, etc. But if two 
distinct bodies can be felt through the parietes, with a 
sulcus between them, it is very probable that the uterus 
contains twins. The evidence amounts almost to certainty, 
if, on applying the stethoscope to two parts of the ab- 
domen remote from one another, the sound of the fcetal 
heart is heard distinctly in each situation. The foetal 
heart gives a double sound, which very much resembles a 
muffled ticking, such as is heard when a watch is placed 
beneath a pillow. The beats of the fcetal heart bear no 
fixed relation in frequency to those of the mother's, but in 
general there are at least twice as many in a given time. 
The discrimination of these sounds requires a quiet room 
and a practised ear ; the student should therefore take 
every opportunity of making himself familiar with them. 



REQUIRING A CONSULTATION. 81 

[The pulsations of the foetal heart will not be heard be- 
fore the fifth month, as a general rule, and then, according 
to Frankenhauser. the heart of the male foetus beats one 
hundred and twenty-four, and that of the female one hun- 
dred and forty-five in a minute, on an average.] 

[An experienced ear may, from the number of beats, 
with a great degree of certainty distinguish the sex of the 
foetus.] 

Management of TicinCases. 

39. The delivery of the first child is to be man- 
aged in the same way as an ordinary labor. As 
soon as it is born and separated from the mother, 
apply a binder round the abdomen, and wait for 
the expulsion of the second child. Do not attempt 
to remove the placenta of the first child until after 
the birth of the second. When this has taken 
place, the two placentae will be expelled together. 
If they remain in the vagina, twist the cords to- 
gether and remove them in the manner directed in 
38, Part I. 

An alarming hemorrhage might ensue if the first pla- 
centa were forcibly separated before the birth of the second 
child, as a large bleeding surface would be thereby ex- 
posed, at a time when the uterus would be incapable of 
close contraction. 

The binder is especially necessary in twin cases, because 
the bleeding surface, which is exposed by the separation 
of the placentae, is twice as large as in an ordinary case. 
Moreover, the uterus, in consequence of previous over- 
distension, is more likely to fall into a state of inertia when 
the labor is over. 

[It is always best to mark the first child.] 

Inaction of Uterus after Birth of First Child. 

m 

40. Sometimes the uterus remains in a state of 



82 CASES NOT USUALLY 

inaction for a considerable period after the birth 
of the first child. Should there be no pains within 
half an hour, you may tighten the bandage, and 
rupture the membranes. Should there be none 
within an hour, you may give ergot, as directed in 
10, Part II., provided the presentation is natural. 
If the second child be not born within an hour and 
a half, you had better send for assistance. 

Authors are somewhat divided in opinion as to the 
treatment of these cases : some recommend immediate 
interference, whilst others advise that they should be left 
entirely to nature ; the majority, however, are in favor of 
a middle course. It is not well to interfere too soon after 
the birth of the first child, because the woman may be 
somewhat exhausted, and may need a little repose. At 
the same time, it is not advisable to delay interference too 
long, e. g., for several hours, because the soft parts, which 
have been well dilated by the first child, will have time to 
contract, and thus any operation (such as turning or the 
application of the forceps) which may be required will be 
rendered much more difficult. If there are symptoms of 
exhaustion after the birth of the second child, a teaspoon- 
ful of brandy may be given, together with rr^xxx of tinct. 
opii. 

In all twin cases, the patient should be informed, when 
the first child is born, that she is likely to give birth to a 
second. 

This should not be told to her abruptly, and at the same 
time she should be cheered by the assurance that in all 
probability she will not have to go through one-tenth part 
of the suffering which she has already endured. 

Tedious Labor from Disproportion between Head 
and Pelvis. 

41. The second stage oflabormaybe retarded 
by a slight disproportion between the size of the 
head and pelvis : thus, the former may be larger 



REQUIRING A CONSULTATION. 83 

than usual, and the latter somewhat contracted, 
either at its brim, cavity, or outlet. If the dispro- 
portion be not great, the uterine efforts will proba- 
bly overcome the resistance, after some hours of 
additional suffering, without any bad result to 
either mother or child. 

The pelvis may be too small in all its proportions, or it 
may be irregular in consequence of disease. (See Note 10, 
Part III.) 

A very large and firmly ossified fcetal head may be a 
cause of difficult labor, especially when the pelvis is not 
roomy ; this cause is more often met with in male than 
female children. 

WJien such Cases may he left to Nature. 

42. Cases of tedious labor from want of room in 
the pelvis require much time and patience, and 
should not be hastily interfered with. You may 
safely leave them to nature, so long as the general 
condition of the woman is good, the pains being 
regular and powerful, and the head advancing ever 
so little in a given time ; the passages being neither 
hot nor tender, and the pulse not rising above 100 
between the pains. 

One of the first lessons which the young accoucheur has 
to learn is patience. Patience enables the adept, who 
knows by experience what pangs nature will endure at 
such times, and yet in the end accomplish her work safely, 
to quietly await the result, when the tyro, listening to the 
suggestions of his own timorous imagination, and to the 
entreaties of the woman and her friends, would rashly re- 
sort to instruments, and, perhaps, sacrifice the lives of the 
mother and her helpless offspring. 



84 CASES NOT USUALLY 

The student should take care not to mistake the elonga- 
tion of the cranium and swelling of the scalp, which are 
so marked in difficult labors, for an advance of the head. 

Retention of Urine daring Labor. 

43. In tedious labors, the pressure of the head 
upon the bladder may cause retention of urine. If 
there be any doubt as to the woman's ability to 
pass water, you should draw it off. For this pur- 
pose, an elastic male catheter is preferable to the 
ordinary instrument. The woman lying on her 
left side, feel for the meatus urinarius with the tip 
of the left forefinger. You will find it beneath the 
pubic arch, and just above the vaginal orifice, from 
which it is separated by a slight projection. Then 
introduce the catheter (previously oiled), push it 
on into the bladder, and receive the urine in a small 
basin. If the child's head resist the catheter, you 
must repress it a little with your fingers. 

Nurses are very apt to confound the dribbling away of 
liquor amnii with passing water, and vice versa. Their 
statements, therefore, must be received with much caution. 

During labor, the urethra becomes elongated, and passes 
almost straight up behind the symphysis pubis. It is on 
this account that a long flexible catheter is preferable. 

When the labor is lingering, the parts of generation 
may become so swollen, that it is difficult to detect the 
meatus urinarius. When such is the case, the parts must 
be exposed to view : it is better to do this than to run any 
risk from long-continued retention of urine. 

The catheter should always be used before turning, or 
employing instruments. 



REQUIRING A CONSULTATION. 85 

Cramps during Labor. 

44. During the second stage of labor, the pres- 
sure of the head upon the sacral nerves occasionally 
produces very painful cramps in the thighs and legs. 
Delivery is the only remedy for these ; but some 
relief may be afforded by friction of the affected 
limb. 

Should simple friction be insufficient, the limb may be 
rubbed with the liniment, chloroform. 

Sometimes the pain arising from cramps is so excru- 
ciating as to render the inhalation of chloroform advisable. 
Before adopting this measure, a consultation should be 
requested. 

Death of Foetus before or during Labor. 

45. The foetus may die either before or during 
labor. If it die before the full term of pregnancy, 
it will be retained until it appears to act as a 
foreign body, and excites the uterus to throw it off. 
The time during which it thus remains may vary 
from a few hours to several clays, or even weeks. 

The death of the foetus may be caused by intra-uterine 
disease, such as syphilis, etc. ; by blows, falls, or other 
shocks, or it may be a result of difficult labor. According 
to the time that the foetus has been retained in utero, it 
may either be slightly decomposed, as shown by some dis- 
coloration and peeling of the cuticle, or it may be so putrid 
and rotten that it will scarcely hang together. 

Signs of Death of Foetus. 

46. When the foetus dies before labor, its move- 
ments cease to be felt, the abdomen subsides, and 



86 CASES NOT USUALLY 

there is a feeling of coldness and weight in the 
uterine region. The breasts become flaccid, and 
lose the characteristic appearance of pregnancy. 
The woman's health suffers ; her breath is offen- 
sive, and her eyes are surrounded by a dark circle. 
During labor, the cranial bones feel loose and 
movable beneath the flaccid scalp, and there is 
no caput succedaneum, however long the labor 
may have lasted. If there be much decomposition, 
the scalp becomes emphysematous, and crackles 
under the linger. The liquor amnii contains me- 
conium ; the discharges are offensive, and flatus 
often escapes from the uterus. But auscultation 
affords the surest sign, both before and during 
labor. If the foetal heart has been heard distinctly, 
and if its pulsations, after a time, become quicker 
and fainter, and cease altogether, you have tolera- 
bly certain proof of the death of the foetus. 

Many of the signs first enumerated are, when taken by 
themselves, extremely equivocal, because they depend very 
much upon sensations which are apt to be fallacious. The 
diagnosis of the death of the foetus may be a matter of 
much importance in difficult labor; for it may determine 
the kind of instrumental interference which is to be em- 
ployed. The looseness of the cranial bones arises from the 
pulpy condition of the brain produced by decomposition. 
The emphysema of the scalp is caused by gas generated 
during putrefaction. When meconium escapes with the 
liquor amnii in a head presentation, it is a suspicious cir- 
cumstance, as it indicates a relaxation of the sphincter 
ani. 



REQUIRING A CONSULTATION. 8T 

Management of Delivery with Stillborn Children. 

47. When the child is dead, the progress of the 
labor is not materially affected. The uterine action 
ma}^, perhaps, be somewhat torpid, and a dose of 
ergot may be necessary. For some days after the 
labor the vagina should be well syringed with 
warm water, in order to wash awa}' any putrid 
matters which may remain behind. This should 
be done once every day at least. 

The absorption of any kind of putrid matter should be 
carefully guarded against, as it is a fertile source of puer- 
peral fever. 

For the purpose of syringing out the vagina, an India- 
rubber bottle, or an ordinary enema apparatus, will answer 
very well. 

Coiling of Cord round Neck — Treatment. 

48. When the child's head is born, it often hap- 
pens that the cord is twisted once or twice round 
the neck. This is seldom a matter of much con- 
sequence, because, in these cases, the cord is gene- 
rally longer than usual. You may draw down a 
loop of the cord so as to relieve its tension, and, 
if you can, slip it over the head. If it be too tight 
for this, you may slip it over the shoulders. When 
the cord is so unusually tight as to threaten 
strangulation of the infant, you may divide it, 
taking care immediately afterwards to secure the 
cut vessels by ligatures. Such a proceeding, how- 
ever, is scarcely ever necessary. 



88 CASES NOT USUALLY 

The coiling of the cord around the neck or limbs ap- 
pears to be a provision of nature for disposing of its super- 
fluous length, and obviating the danger of prolapse. 

If, as very seldom happens, a short cord be tightly 
twisted around the neck, the child is in danger both of 
strangulation and compression of the cord. There is also 
some risk of forcible detachment of the placenta, or even 
an inversion of the uterus. 

Delay in Expulsion of Body — Treatment. 

49. Sometimes there is a considerable delay after 
the birth of the child's head. The face becomes 
livid and much swollen, and the child appears in 
imminent danger of strangulation or apoplexy. If 
after ten minutes the body should not be expelled, 
the delivery may be assisted by making firm pres- 
sure on the fundus uteri, and using gentle traction 
upon the neck, or, still better, upon the trunk, by 
passing up the forefinger along the neck and hook- 
ing it round the axilla. 

The pressure upon the fundus uteri is made for the pur- 
pose of inducing uterine contraction, and thus obviating 
the danger of post-partum hemorrhage. 

Asphyxia of Infant — Causes. 

50. When the child is born, it may be in a state 
of suspended animation from asphyxia; the heart 
beats, but there are no respiratory efforts. This 
condition may arise from various causes, such as 
pressure on the head during a long labor, flooding 
from premature detachment of the placenta, com- 
pression of the cord or neck during birth, etc. 



REQUIRING A CONSULTATION. 89 

In some instances, the condition of the child borders 
closely upon syncope from anaemia; such would be the 
result of flooding from premature detachment of the pla- 
centa. In others, there is a state of cerebral congestion 
approaching apoplexy, and this we should expect to find 
where there has been a long interval between the birth of 
the head and the body, and, consequently, much pressure 
on the neck. 

Treatment of Asphyxia. 

51. If the cord pulsates you should not, as a 
general rule, tie it for at least a quarter of an hour ; 
but if the child appears to be in an apoplectic con- 
dition, as shown by great swelling and lividity of 
the countenace, you may at once divide the cord, 
and allow two or three teaspoonsful of blood to 
escape from it. In all cases you may first attempt 
to induce respiration by exposing the face freely 
to the air, and sprinkling it with cold water ; by 
wetting the trunk and limbs with brandy, and rub- 
bing them briskly with warm flannels. You may 
try these means for a minute or two; but if they 
fail, you must have recourse to artificial respira- 
tion without delaj r . 

The popular remedy, amongst nurses, of slapping the 
child's buttocks will sometimes succeed in producing a re- 
spiratory effort. Galvanism is a powerful means of resus- 
citation when a proper apparatus is at hand. 

Other means of exciting respiration have been recom- 
mended, such as holding ammonia or burnt feathers to the 
nostrils, tickling the fauces with a feather, etc. 

Care should always be taken in these cases to free the 
mouth or fauces from any mucus which may clog them. 

The contact of cold air with the skin is a powerful 
8* 



90 CASES NOT USUALLY/ 

stimulus to the respiratory act, and therefore the child's 
face should always be freely uncovered. 

The limbs should be rubbed with gentle pressure up- 
wards, in order to promote the circulation by propelling 
the venous blood towards the heart. 

Mode of performing Artificial Respiration. 

52. The most efficient means of resuscitation is 
undoubtedly artificial respiration. To perform 
this, first place the infant briskly in the prone 
position, so as to clear the fauces of mucus or 
other fluids. Then place it in a sitting posture, 
and alternately raise it up by the arms and set it 
down again, about twenty times in a minute. Each 
time that the child is set down the arms should be 
pressed gently against the sides and the head in- 
clined forwards. These movements should be con- 
tinued until the child breathes with regularity ; and 
they should not be abandoned as hopeless whilst 
the least pulsation of the heart is perceptible. 

The mode of performing artificial respiration which has 
been just mentioned is, with some slight modifications, the 
same as Dr. Silvester's, whose plan received the approval 
of the Medico-Chirurgical Society. It has been found to 
be a more effectual method of inflating the chest than 
that recommended by the late Dr. Marshall Hall. The 
latter, however, will in many cases, answer very well, 
and is thus performed : Place the infant in the prone po- 
sition, make gentle pressure on the back of the thorax, 
and then remove that pressure, turn the child on the side 
and a little beyond. This should be repeated about 
twenty times in a minute. The child is then to be placed 
with the face prone, and douched rapidly with hot and 
cold water alternately. 

The old-fashioned mode of performing artificial respira- 



REQUIRING A CONSULTATION. 91 

tion is still preferred by some, and consists in inflation of 
the lungs by means of a proper tube, or, in default of it, 
a quill or piece of tobacco pipe. If the tube is used, it 
should be inserted into the larynx. To do this, the fore- 
finger of the left hand should be passed over the root of 
the tongue until it reaches the epiglottis. The end of the 
tube is then to be passed between the tip of the finger and 
the posterior surface of the epiglottis, and introduced 
into the rima glottidis. If a quill or tobacco pipe is used, 
the child's lips are pressed around the tube and its nostrils 
closed ; at the same time the larynx is pressed backwards 
so as to shut the oesophagus. The lungs are then inflated 
by alternately blowing into the mouth and depressing the 
ribs with the hand. Care should be taken not to inflate 
too forcibly, for fear of rupturing some of the pulmonary 
air-cells. This method, however, is inferior in efficacy to 
the two others, and especially to the first. It does not 
imitate the natural respiratory movements so closely, and 
it may injure the delicate tissue of an infant's lung. But 
yet, in any case, whenever one plan appears to fail, another 
may be tried. 

It is sometimes necessary to continue artificial respira- 
tion for at least an hour and a half. 

The hot and cold water used for sprinkling the child 
should be respectively of the temperature of about 60° 
and 100° Fahr. 

[Xo method of resuscitating the asphyxiated is 
equal to that form of artificial respiration, consist- 
ing simply of blowing air from your own lungs 
into the mouth of the infant, and closing the nostrils 
of the child at the same time. No tube or pipe is 
needed, the physician placing his mouth in direct 
contact with that of the child. At the same time 
the feet are to be kept warm, and a stimulating 
enema may be thrown into the rectum. By these 
means resuscitation may be accomplished, even 
after a long continuance of the asphyxia. 



92 CASES NOT USUALLY 

About a year since I attended a case of labor, and the 
child did not show the slightest signs of life for thirty- 
three minutes. The above means were used, and after the 
above time the child gave its first gasp. The attendant, 
therefore, should never abandon the child as dead until he 
has used every means towards resuscitation for at least an 
hour and a half.] 

Post-Partum Hemorrhage, or u Flooding y 

53. The flow of blood which usually accompanies 
the separation of the placenta may be so excessive 
as to produce marked constitutional symptoms. It 
is then called post-partum hemorrhage, because it 
follows the birth of the child. The hemorrhage is 
always occasioned by uterine inertia, and, if pro- 
fuse, may cause pallor of the lips and face, weak, 
fluttering pulse, faintness, sighing respiration, dim- 
ness of sight, dysphagia, jactitation, convulsions, 
and death. 

Post-partum hemorrhage is always a dangerous and 
alarming accident, requiring prompt and vigorous treat- 
ment. 

Every student who attends midwifery should know how 
to meet such cases when they occur. Dr. Gooch has well 
remarked, "In these cases you would give anything for a 
consultation, but there is no time for it; the life of the 
patient depends on the man who is on the spot ; he must 
stand to his gun, and trust to his own resources. A prac- 
titioner who is not fully competent to undertake these 
cases of hemorrhage can never conscientiously cross the 
threshold of a lying-in chamber." 

In most cases of post-partum hemorrhage an unnatural 
rapidity and jerking of the pulse may be noticed before 
the actual occurrence of flooding. Dr. Churchill, in his 
" Theory and Practice of Midwifery," has made some 
valuable remarks on this point. He says: "In almost all 



REQUIRING A CONSULTATION. 93 

the cases of flooding after labor, when I have had an op- 
portunity of examining the pulse, up to the time of the 
occurrence, I have found it remain quick, and perhaps 
full, instead of sinking after delivery. This has been so 
marked in several cases that I now never leave a patient 
so long as this peculiarity remains ; and in more than one 
instance I believe the patient has owed her safety to this 
precaution. Three cases occurred within a very short 
time of each other, in which I noticed this undue quick- 
ness of the pulse, without any other untoward symptom; 
at that time there was no excessive discharge, and the 
uterus was well contracted. In all these, alarming hemor- 
rhage occurred within an hour, and was with difficulty 
arrested." 

[" It is in instances like these that promptness, 
decision, and energy must take the place of sym- 
patic In 163,138 cases hemorrhage occurred 1338 
times, or about 1 in 122. Out of 782 cases of 
hemorrhage, 126 mothers were lost." "Dr. Collins 
reports 44 cases of hemorrhage after expulsion of 
the placenta. In 31 of these, the child was of the 
male, and in 13, or less than one-third, it was of 
the female sex."] 

Symptoms of Post- Par turn Hemorrhage. 

54. In most cases of post-partum hemorrhage 
the flooding is sufficiently obvious, both to the 
woman and her attendants, for the blood will gush 
forth upon the bed-clothes and mattress until they 
are saturated, and then run in a full stream on the 
floor. The uterus will be felt to be in a relaxed 
and flabby condition, so that you can scarcely de- 
fine its limits ; or, if it contract and harden for a 



94 CASES NOT USUALLY 

few seconds, it will speedily return to its former 
state. 

In all cases where there is any reason to apprehend 
hemorrhage, the pulse should be frequently felt, and the 
uterus examined. The patient should be asked whether 
she feels any discharge running from her ; and the napkin 
should be frequently removed and inspected. 

Treatment of Post-Par turn Hemorrhage. 

55. In treating post-partum hemorrhage, the chief 
indication is to produce uterine contraction. For 
this purpose, grasp the uterus firmly with one or 
both hands, and keep up the pressure for a con- 
siderable period. Apply frequently cold wet cloths, 
or a bladder containing ice, to the vulva, hj^pogas- 
trium, and thighs. Keep the woman's head low 
by taking aw r ay the pillows, and remove all the 
clothes, except a sheet, from the lower part of 
her body. Give a full dose of ergot immediately. 
This may be followed in a quarter of an hour 
by a tablespoonful of oil of turpentine. If there 
be much tendency to syncope, give stimulants, 
such as brandy, ether, or sal volatile. Do not 
leave the woman for at least three hours after 
the birth of the child, nor until the uterus remains 
well contracted. Before leaving, give an opiate 
to tranquillize the nervous system. Also place a 
good-sized compress upon the uterus, and apply a 
binder firmly round the abdomen. [This rule laid 
down here, of giving opium, seems to me very 
questionable. A young student or physician may 



REQUIRING A CONSULTATION. 95 

attend his first case of post-partum hemorrhage, 
and having administered the opiate, leave his 
patient, and under its influence the uterus may be 
relaxed, and the life lost. Better not leave the house 
till the uterus is hard like a " cannon ball." If 
opium is used, let it be as a gentle general seda- 
tive.] 

3j of the Extractum Ergotse Liquid, may be given at 
once in these cases. If the woman be a multipara, who 
has previously suffered from post-partum hemorrhage, it 
is an excellent plan to give the ergot shortly before the 
birth of the child. Hemorrhage may be thus entirely 
prevented. 

The oil of turpentine may be given with an equal pro- 
portion of milk. 

If the uterus do not contract when grasped, it may be 
pressed and kneaded by the hands in various ways, or 
friction may be made on its surface, through the loose 
abdominal parietes. The cloths may be wetted with vine- 
gar and water. The more suddenly they are applied the 
better. 

A tablespoonful of brandy, or a teaspoonful of sal vola- 
tile, may be given at a time. The sal volatile may be 
given either in milk or water. 

The dose of opium given should be about "nixxx of the 
tincture. 

One of the best compresses which can be used in these 
cases is a large old-fashioned pin-cushion, such as is often 
seen in lying-in rooms garnished with " Welcome, little 
stranger," or some other appropriate device, in pins. 
After carefully ridding it of all pins and needles, the 
cushion may be turned to good account in the way men- 
tioned. In default of it, two or three folded napkins, or 
a small thick book may be used. 

Should the means above recommended be not successful 
in speedily checking the hemorrhage, the student should 
send for assistance without delay. 

There are several other methods of inducing uterine 
contraction, in case the above expedients do not answer. 



96 CASES NOT USUALLY 

Some of them, however, require much skill, and would be 
attended with considerable risk, in the hands of an inex- 
perienced student. One of the safest and simplest is the 
cold douche. As Dr. Marshall Hall has shown, it is a 
very powerful means of exciting reflex uterine contrac- 
tion. The abdomen being uncovered, a stream of cold 
water is to be poured upon the hypogastrium from a con- 
siderable height, by means of a jug. 

Injections of cold water into the rectum will frequently 
succeed in arresting uterine hemorrhage. The applica- 
tion of the child to the breast is another safe and simple 
remedy, and has been strongly recommended by Dr. Rigby. 
[See p. 46. J A contraction of the uterus is produced 
from the sympathy between that organ and the mamma, 
This expedient is well worthy of a trial in all cases of 
flooding after labor. 

Compression of the abdominal aorta has been frequently 
successful in post-partum hemorrhage. 

The introduction of the hand into the uterus will some- 
times excite that organ to contract, when other means 
fail. 

When the hand is in the uterus, it may be moved about, 
so as to increase the stimulus occasioned by its presence. 
The bleeding vessels may also be compressed between the 
knuckles of that hand, and the palm of the other, placed 
on the outside of the abdomen. This proceeding should 
only be adopted when others fail, as it is attended with 
some risk of uterine inflammation. 

Dr. Tyler Smith speaks very highly of injections of iced 
water into the uterus as a means of arresting hemorrhage. 

Dr. Robert Barnes strongly recommends injections of 
perchloride of iron into the uterus. He uses a solution 
consisting of four ounces of liquor ferri perchloridi fortior 
of the British Pharmacopaeia, with twelve ounces of water. 
This should be thrown up by means of a Higginson's 
syringe, and long elastic tubes. Galvanism has been 
frequently applied with good effect in cases of uterine in- 
ertia. 

Lastly, women have been saved when in imminent dan- 
ger of death from hemorrhage, by the operation of trans- 
fusion, which consists in abstracting blood from the vein 
of a healthy person, and injecting it into the vein of the 



REQUIRING A CONSULTATION. 97 

patient. But this operation, as well as some of those 
mentioned just before, should not be attempted without a 
consultation. 

[If there is any organic disease of the uterus, as fibroid 
tumors for example, it will be well to compress the aorta.] 

Internal Hemorrhage — Diagnosis. 

56. In some instances, which are not very com- 
mon, there is no external hemorrhage, but the 
bleeding takes plaee internally, into the cavity of 
the uterus. The usual symptoms of hemorrhage 
appear, but without discharge of blood. The uterus 
swells, and becomes almost as large as if it con- 
tained a second child ; but, at the same time, feels 
soft and doughy, and not firm and hard, like a 
uterus containing a child. On examining, you find 
its cavity filled with fluid blood and coagula. 

In internal hemorrhage, the os uteri is closed by the 
detached placenta, by a coagulum, or by a circular con- 
striction of its fibres, etc. 

Treatment of Internal Hemorrhage. 

57. In internal hemorrhage, the first indication 
is to facilitate the flow of blood through the os 
uteri, and the next to insure uterine contraction. 
To accomplish the first, introduce your hand into 
the uterus, and remove the detached placenta, or 
any large coagula which may obstruct the open- 
ing of the os. Then use the means for producing 
uterine contraction, which have been before de- 
scribed. 

9 



98 CASES NOT USUALLY 

In all cases of post-partum hemorrhage, the placenta 
should be removed when detached, whether it be in the 
uterus or vagina. 

When the woman is in the ordinary position, the left 
hand will be found the most convenient for introduction 
into the uterus, because it is better adapted to the curve 
of the sacrum. 

Those clots only ought to be removed which are de- 
tached, and in the lower part of the uterus. The removal 
of clots which are adherent to the uterine parietcs would 
be very likely to cause a great increase of flooding. 

After-pains. 

58. Women, after delivery, are liable to painful 
contractions of the uterus, which are called " after- 
pains." These are very common in multipara, but 
comparatively rare in primapara. They come on 
immediately after the expulsion of the placenta, 
and may continue for many hours, or even for one 
or two days. They recur at intervals, like labor 
pains, and often serve to expel coagula and other 
matters from the uterus. 

Although after-pains occasion much suffering, they sel- 
dom give rise to any fever, or abdominal tenderness. The 
woman feels quite easy between each pain. The suffering 
produced by them is borne with much impatience, from a 
belief that they do no good. This idea is not strictly cor- 
rect, as they are frequently caused by efforts which the 
uterus makes to get rid of clots, or portions of membrane 
remaining in its cavity. Nevertheless, it is certain that 
in some of the worst cases of after-pains, no such cause 
can be detected. 

Treatment of After-pains. 

59. As a general rule, after-pains should not be 
checked, in any way, for at least six hours after 



REQUIRING A CONSULTATION. 99 

delivery ; if b}^ that time the}' continue with un- 
abated severity, and seem likely to prevent sleep, 
you should give an opiate, and this may be re- 
peated every six hours if necessary. Warm fomen- 
tations to the abdomen are also of service. 

Should the uterus feel larger and harder than usual, 
there is in all probability something within its cavity which 
it is endeavoring to throw off. An examination may there- 
fore be made, and if any clot or portion of membrane be 
detected by the finger, it should be removed. Purgative 
enemata are of much service in promoting the expulsion 
of clots. 

In order to check after-pains, lUxv of tinct. opii may be 
given, at a time, in gj mist, cam ph. 

The most convenient kind of warm fomentation is the 
application of large flannels wrung out of hot water. 
These should be covered over with dry flannel, or, what is 
better, a piece of oiled silk or sheet gutta percha. A 
large piece of spongio piline will answer the same purpose 
very well. 

[It is best even before giving the sedative to remove 
clots or membranes in the uterus or vagina, as this may be 
the cause of the pains. Also examine the rectum and 
bladder.] 

Nervous shock after Delivery. 

60. Some women, especially those of hysterical 
temperament, show symptoms of a severe nervous 
shock after delivery. They appear much exhausted, 
and are liable to attacks of syncope. There is 
often severe headache, and much intolerance of 
light and sound. The pulse is soft and compressi- 
ble ; sometimes slower, but much more frequently 
faster than usual. The countenance is pale and 



100 CASES NOT USUALLY 

anxious, the tongue moist and tolerably clean, the 
skin soft and perspirable. 

When the headache depends upon constipation or dis- 
ordered bowels, the tongue will be coated with fur, and 
very probably red at its tip and edges. 

Should it depend upon any inflammatory affection of the 
abdominal organs, the secretions of milk and lochia will 
be checked. 

Should there be much tendency to syncope, a stetho- 
scopic examination of the heart should be made, to ascer- 
tain whether there is any organic disease of that organ. 

Treatment of Nervous Shock. 

61. When there is a severe nervous shock after 
delivery, the best remedy is an opiate combined 
with a diffusible stimulant ; and this may be re- 
peated, if necessary, in smaller doses every four 
hours. The most perfect repose should be enjoined. 
The head should be placed rather lower than usual, 
and the horizontal posture strictly maintained. 

The following draught will answer the purpose very 
well : — 

R. — Liq. morphise hydrochlor., rn^xxx 1 . 

Spt. ammon. foetid., gss. 2 

Aq. camph. ad ^jss. 
M. ft. Haustus statim sumend. 

Or this :— 

R. — Liq. morphise acetat., tt^xxx. 

Trse. Sumbnl., rr^xx. 

Spt. Chloroform., ""Ix. 

Aq. camph. ad gjss. 
M. ft. Haustus statim sumend. 



1 [Sol. morphise muriat.] 

2 [L. E. D. Useless preparation, according to Prof. Carson.] 



REQUIRING A CONSULTATION. 101 

Sleeplessness after Delivery. 

62. Women of a nervous excitable temperament 
are sometimes troubled with insomnia or sleepless- 
ness after delivery. This requires absolute repose 
and quiet; tea and coffee should be forbidden, and 
an opiate or a dose of hydrate of chloral adminis- 
tered. 

The following will be found to be a good form of opiate : 

R. — Liq. morphias acet, rr^xxx. 

Spt. chloroform, t*\x. 

Aq. camph., §jss. 
M. ft. Haust. hora somni sumend. 

Hydrate of chloral is often a more effectual remedy for 
insomnia than opium, and does not leave, like opium, un- 
pleasant after effects. 
It may be given thus : — 

R. — Chloral Hydrat., gr. xxx. 
Syrup. Aurantii, ^ij. 
Aquam ad giij. 
M. ft. Haust. hora somni sumend. 

Or two scruple doses may be given as recommended in 
11, Part II. 

[Great care should be observed in the administration 
of chloral.] 

Retention of Urine after Delivery — Treatment. 

63. Retention of urine is sometimes a conse- 
quence of a tedious labor, and arises from swelling 
of the vaginal orifice and meatus urinarius, to- 
gether with some loss of power in the bladder. 
You may first try the application of warm fomen- 
tations to the vulva; if these do not produce the 
desired effect, you must use the catheter. If the 

9* 



102 CASES NOT USUALLY 

inability to pass water continue, tonics and diu- 
retics should be given. 

The following mixture may be administered in these 
cases : — 

R. — Tinct. ferri perchlorid., 
Spt. aeth. nit,, aa^j. 
Aquam ad gviij. 
M. Capt. sextam partem ter die. 
Sometimes when the patient has been weakened by 
tedious labor or flooding, there will be inability to pass 
water so long as she remains in the supine position ; but 
a slight change of position, such as elevating the shoulders 
(if not otherwise improper), or turning on the elbows and 
knees, w T ill suffice to overcome the difficulty. 

Incontinence of Urine after Delivery — its 
Treatment. 

64. Incontinence of urine is occasionally a result 
of tedious labor, and is caused by temporary para- 
lysis of the sphincter vesicae from long-continued 
pressure. If the power of retaining the urine be 
not recovered in a few days, preparations of iron 
or other tonics should be given. 

The following formula is a suitable one : — 
R. — Tree Cantharides, 

Trae ferri perchlor., aa gj. 
Syrupi, gij. 
Aquae, gvijss. 
M. Sumat. sextam partem ter die. 
Should this fail, the following mixture may be had re- 
course to :— 

R. — Liquor Strychnia?, rr^xxx. 
Syrupi, ^ij. 

Trae. ferri perchlor., gij. 
Aquae, gvijss. 
M. Capt. sextam partem ter die. 



REQUIRING A CONSULTATION. 103 

The author has found this mixture of the greatest ser- 
vice both in retention and incontinence of urine, arising 
from loss of power in the bladder after delivery. 

Incontinence of urine sometimes arises from sloughing 
of the base of the bladder after very severe labor. Incon- 
tinence from this cause does not come on immediately after 
delivery, and is generally preceded by much local pain, 
tenderness, and fetid discharge, accompanied with conside- 
rable fever and constitutional irritation. When such symp- 
toms are present, the student should request a consultation. 

Deficiency of Lochial Discharge — Treatment 

65. The lochial discharge may be deficient in 
quantity, or may entirely disappear within two or 
three days after delivery. This is not unusual after 
the birth of stillborn children, and need occasion 
no alarm, provided it be unaccompanied with febrile 
symptoms. The treatment is to apply warm fo- 
mentations to the vulva, and syringe the vagina 
daily with warm water. 

Suppression of the lochia is one of the symptoms of puer- 
peral fever, and is then an effect rather than a cause of 
constitutional disturbance. 

Excessive Lochial Discharge — Treatment. 

66. In other cases the lochia may be excessive in 
quantity, or may last beyond the usual time, pro- 
ducing much debility. The proper treatment is to 
enjoin rest, and to give tonics, such as quinine and 
iron. In some cases ergot of rye is of great ser- 
vice ; in others, astringent injections are of much 
use. 



104 CASES NOT USUALLY 

Sulphate of quinine may be given in two-grain doses 
with rr^x of acid. Sulph. dil. to each dose. Of the pre- 
parations of iron, the tincture of the perchloride answers 
the best, and may be given in ti\x doses twice a day. 
Weak injections of sulphate of zinc and alum are the most 
suitable. Decoctions of oak-bark or tormentilla will also 
answer very well. Too much exercise within the first fort- 
night or three weeks after delivery may cause the red dis- 
charge to return, and even put on a hemorrhagic character 
(See 68, Part II.) after having lost its color and almost 
disappeared. When this happens, the patient should be 
kept perfectly quiet in the horizontal posture, and should 
take five grains of powdered ergot of rye, three times a 
day. 

Offensive Lochial Discharge — Treatment. 

6T. In other cases the quality of the lochia is 
altered, the color being dark, and the odor very 
offensive. This may depend upon the presence of 
putrid matter in the uterus, such as decomposed 
portions of placenta, clots, &c. The vagina should 
be syringed two or three times a day with warm 
water or with weak disinfectant lotions. 

Putrid and decomposing matters within the uterus are 
a fertile source of phlegmasia dolens, or even puerperal 
fever. (See 33 and 34, Part III.) They ought, therefore, 
to be carefully removed. The patient should be directed 
to pass water when resting on the elbows and knees ; as 
clots, &c, will more readily come away in this position, 
because the vagina and outlet of the pubis are then di- 
rected downwards. In some cases it may be advisable to 
wash out the internal surface of the uterus. 

The following disinfectant lotion may be used: — 
R. — Liq. sodae chloratae. gss. 

Aquae destillat. ad Oj. 
M. ft. lotio. 



REQUIRING A CONSULTATION. 105 

Or what is still better, 

R. — Liq. potass, permanganate., ^iij. 

Aq. destillat. ad Oj. 
M. ft. lotio. 

Secondary Hemorrhage — Causes. 

68. Secondary Hemorrhage is a sudden loss of 
blood from the uterus, occurring some hours after 
delivery, or even at any period within the month. 
It is most usually caused by the retention of a 
portion of adherent placenta, or of a large clot in 
the uterus ; but it may arise from uterine relaxa- 
tion, disturbance of the circulation, laceration, or 
disease of the uterus, &c. 

In all these cases a careful investigation should be 
made to ascertain, if possible, the cause of the hemor- 
rhage. For instance, the history of the case, and the 
undue size of the uterus, may lead to suspicion of re- 
tained portions of the placenta or clots ; to make sure of 
this a careful vaginal examination should be made. 

Secondary Hemorrhage — Treatment. 

69. The treatment of secondary hemorrhage 
must depend very much on the cause. Portions 
of placenta or clots should be removed, if possible ; 
and the hemorrhage should be restrained by cold 
applications, cold enemata, ergot of rye, and tur- 
pentine. 

The ergot of rye may be thus given : — 

R. — Ext. ergot, liquid., ^j. 

Aq. cinnam. ad giij. 
M. Capt. tertiam partem omni hora. 



106 CASES NOT USUALLY 

After this has been taken, turpentine may be adminis- 
tered~as follows: — 

R._01. Terebinth., gj. 

Mucilag. q.s. 

Syrupi, gj. 

Aquam, ad ^vj. 
M. Sumat 6tam partem ter die. 

Lacerated Perineum. 

TO. Slight lacerations of the perineum, which 
merely pass through the thin anterior edge of the 
mucous membrane or fourchette, are very common, 
especially in first labors, and give rise to little or 
no inconvenience. But sometimes the laceration 
extends further, passing through the whole sub- 
stance of the perineum, even as far as the sphincter 
ani. In other cases, happily by no means com- 
mon, the rent passes through the sphincter ani, 
and sometimes even the recto-vaginal septum, 
laying the vagina and rectum open into one pas- 
sage. 

The fourchette is almost always lacerated in first labors, 
without any subsequent inconvenience being occasioned. 

A laceration of the perineum, properly so called, seldom 
heals by the first intention, if unattended to, because the 
wound is kept open by the constant passage of the dis- 
charges over it, as well as by the action of the sphincter 
ani. When the laceration extends through the recto- 
vaginal septum, the patient loses the power of retaining 
her faeces, which are liable to come away, at any time, 
involuntarily. Her after condition is consequently most 
deplorable. 



REQUIRING A CONSULTATION. 107 

Lacerated Perineum — Treatment. 

71. Slight lacerations of the perineum require 
little or no treatment. It will generally be enough 
to keep the parts clean, to direct the woman to lie 
on her side, and to tie the knees together. When 
more severe they should be treated at once, so as 
to insure, if possible, union by the first intention. 
The edges of the wound should be brought to- 
gether by three or four sutures of silver wire or 
silk. 

The interrupted suture is the best for ordinary use, and 
silver wire is, in the opinion of the author, preferable to 
silk. The best form of needle is the old-fashioned semi- 
circular one. The needle should pass through the whole 
thickness of the perineum, and should pierce the skin at 
a distance of at least a quarter of an inch from the edges 
of the wound. The sutures may be removed at the end 
of a week. 

Should the lacerated perineum not unite by the first 
intention, a surgical operation will, in all probability, be 
ultimately required to effect reunion. Most of the surgi- 
cal operations for the cure of lacerated perineum consist 
in paring the edges of the wound, and bringing them 
together by sutures of various kinds. 

Mr. I. B. Brown's work on " Diseases of Women" 
admitting of surgical treatment, gives a full account of 
these operations. 

Prolapsus Uteri — its Treatment. 

72. Prolapsus uteri, or " falling down of the 
womb," is a very common complaint amongst the 
poor. It nearly always arises from getting up too 
soon after delivery, before the parts have had time 



108 CASES NOT USUALLY 

to recover themselves. When it happens within 
the month, the woman should be kept in bed two 
or three weeks longer than usual, and (if the 
lochia have ceased) should use astringent injec- 
tions. 

There are various degrees of prolapsus uteri, from the 
slightest subsidence within the pelvis to a complete ap- 
pearance of the organ externally. 

Prolapsus uteri is usually occasioned by some bearing- 
down effort within a few days after delivery, when the 
uterus is large and heavy, and all the parts which surround 
it and keep it in its place are relaxed and unable to sup- 
port its weight. It is not at all uncommon to find poor 
women on the third day after delivery sitting up, and even 
attending to their household affairs. Hence the fre- 
quency of prolapsus uteri is not to be wondered at. 

Women who have previously suffered from prolapsus 
uteri have sometimes been cured by remaining in bed two 
or three months after their confinement. 

Injections of tannin, oak bark, alum, sulphate of zinc, 
&c, may be used for the treatment of prolapsus. 

Paralysis of legs after Delivery — Treatment. 

13. Paralysis of one or both legs is sometimes 
met with after labor, and is caused by pressure on 
the sacral nerves during the second stage. There 
is a loss of power, and frequently, also, pain and 
numbness in the affected limbs. These symptoms 
usually subside after three or four days, but in 
some instances last much longer. Warm fomenta- 
tions to the parts may be used, and also frictions 
with stimulating liniments. 

The following liniment is a suitable one for such 
cases: — 



REQUIRING A CONSULTATION. 109 

R. — Liq. ammon. fortior., gj. 

01. olivog, §jss. 

01. terebinth., gss. 
M. ft. liniment., ter die utend. 

This kind of paralysis is a purely local affection, aris- 
ing from the same cause as cramps during labor. (See 
44, Part II.) 

How to get rid of Secretion of Milk. 

74. Women who have lost their infants, or who 
from any cause are prevented from nursing, are 
apt to suffer much inconvenience from accumula- 
tion of milk in the breasts. You must, therefore, 
take means to relieve the distended breasts, and 
also to get rid of the secretion of milk. For this 
purpose, a spare, dry diet should be enjoined. 
The bowels should be moved every other day by 
laxatives, such as castor oil, etc. Saline diapho- 
retics and diuretics may also be given. The 
breasts should be rubbed with warm oil, or covered 
with soap plasters spread on leather. If they are 
much distended they should be rubbed with bella- 
donna ointment, and a little milk should be drawn 
off by means of a syringe or breast-pump, taking 
care to abstract only just so much as is necessary 
to relieve tension. 

The following mixture may be given : — 

R. — Yin. antimonial., 

Spt. agth. nit., aa gij. 

Liq. ammon. acet., £j. 

Aq. cam ph. ad §viij. 
M. Oapt. sextam part ter die. 

10 



110 OASES NOT USUALLY 

Belladonna appears almost to have a specific effect in 
checking the secretion of milk, and relieving tension of 
the breast. The extract of belladonna should be mixed 
with an equal quantity of glycerine, and applied in a circle 
around the areola every night. 

The breasts should never be completely emptied of milk, 
as this would only stimulate them to increased secretion. 

[Tea should be avoided, and coffee should be 
used. The former increases the lacteal secretion, 
while the latter very decidedly suppresses it.] 

Retracted Nipples — Treatment. 

75. In some women the nipples are retracted, and 
so short that the child cannot seize them. In con- 
sequence of this malformation, all its efforts to suck 
are useless. Retracted nipples should be drawn 
out by means of an air-pump immediately before 
putting the child to the breast; which ought to 
be done before they are much distended. The use 
of a nipple-shield will sometimes enable the child 
to get at the milk. 

Retraction of the nipple is produced by various causes, 
amongst which may be mentioned pressure from articles 
of dress, such as stays, etc. 

It may be caused also by inflammation set up by the 
absurd and mischievous practice of pulling and squeezing 
the nipples of newly-born female children in order to 
" break the nipple strings," as the phrase is among 
nurses. 

In the absence of a breast-pump, nurses are in the 
habit of drawing the nipples by suction with the mouth, 
or through a tube made for the purpose. 

An older and stronger child will sometimes succeed 
when a newly-born infant has failed. 

There is a common substitute for an air-pump which 



REQUIRING A CONSULTATION. Ill 

will answer well enough in many cases. A decanter or 
soda-water bottle is filled with hot water ; the bottle is 
then emptied, and the nipple immediately inserted into 
its mouth. As the air cools within the bottle, a vacuum 
is created, which causes the nipple to project into it. 

Sore Nipples. 

76. Sore nipples are a frequent and distressing 
result of repeated applications of the child to the 
breasts. The soreness depends upon the presence 
of excoriations, chaps, fissures, or even deep 
ulcers upon and around the nipple. These usually 
appear in a few days after delivery, and, if severe, 
cause great pain, and sometimes bleed freely 
during lactation. 

The nipples are more likely to become excoriated when 
they are retracted, or when, from any other cause, the 
child has much difficulty in seizing them. 

A thin, tender skin, and a want of sebaceous secretion, 
will both predispose the nipples to excoriation. 

Soreness of the nipples is sometimes caused by an 
aphthous condition of the child's mouth. 

Sore Nipples — Treatment. 

77. You may treat simple excoriations of the 
nipples b}^ painting them with tincture of catechu, 
or washing them with weak lotions of alum or 
sulphate of zinc. If the excoriations are limited 
to the base of the nipple or its areola, you may 
cover them with a thin layer of collodion. But if 
there are deep fissures or ulcers, no application is 
so good as a solution of nitrate of silver. In all 



112 CASES NOT USUALLY 

severe cases, the nipple should be protected during 
suckling b} r means of a proper shield. 

The tincture of catechu should be undiluted ; it may be 
applied once or twice a day by means of a earners hair 
brush. 

The lotions of alum and sulphate of zinc may be of the 
strength of 9j to ,^vj of water; that of the nitrate of 
silver, gr. x to ^j of rose-water. These may be used 
twice a day. 

Burnt alum and ung. hydrarg. nitratis may be applied 
in some cases. 

[If the soreness of the nipples results from an aphthous 
condition of the child's mouth, a strong solution of chlo- 
rate of potash will be found most efficacious. Nipples 
should be washed with warm milk and water before and 
after nursing.] 

As most of these applications may have an injurious 
effect upon the child, the nipples should be carefully 
washed before it is put to the breast. 

Collodion should not be applied over the apex of the 
nipples so as to obstruct the milk ducts. 

Nipple-shields are of various kinds, and are made of 
metal, wood, or glass, with a cow's teat adapted to them, 
or an artificial teat consisting of wash-leather or India- 
rubber. In women who have suffered from sore nipples 
after previous confinements, it is a good plan to harden 
the skin of the nipples beforehand by washing them once 
a day with brandy and water, or painting them every 
other day with tincture of catechu. 

Inflammation of Breasts — Symptoms. 

78. The engorgement which accompanies the 
first flow of milk predisposes the breasts to inflam- 
mation, and this is easily excited by any sudden 
exposure to cold, or mental emotion. Inflamma- 
tion also may extend to the breast from a sore 
nipple. The inflammation is phlegmonous in its 
character. There is local pain, soreness, redness. 



REQUIRING A CONSULTATION. 113 

and circumscribed hardness. It is accompanied 
with febrile excitement, and temporaiy suspension 
of the secretion of milk. It may terminate in 
resolution or in suppuration. 

The inflammation may involve only one or two lobules, 
and be comparatively superficial, or it may affect the 
whole breast and be deep-seated. The axillary glands are 
then hard and painful. When suppuration sets in, the 
inflammed part softens in the centre, the skin becomes 
thin, and the pus, after a few days, escapes. The abscess 
usually points near the nipple ; but in persons of bad con- 
stitution the matter may be deep-seated, and may burrow 
extensively beneath the glandular structure of the breast. 
After a long time the abscess gives way, and a quantity 
of matter escapes, together with curdled milk, and sloughs. 
Such cases, if left to themselves, are extremely tedious ; 
troublesome sinuses are formed, which occasion great im- 
pairment of the general health. 

In all cases the discharge of matter is considerable, and 
is accompanied, for a time, with night-sweats and other 
hectic symptoms. 

The suppuration not unfrequently occasions so much 
induration of the breast affected, as to destroy its future 
use. 

Inflammation of Breasts — Treatment. 

79. Inflammation of the breast should be treated 
at its commencement by the application of ten or 
fifteen leeches to the part affected ; or, if there is 
much fever, by general bleeding. The whole 
breast should then be covered with a soft linseed- 
meal poultice. Saline purgatives should be given, 
together with tartar-emetic diaphoretics. If the 
inflammation go on to suppuration, 3-ou should 
let out the matter with the lancet, as soon as } r ou 
10* 



114 CASES NOT USUALLY 

can detect fluctuation. In all these cases, how- 
ever, you had better request a consultation. 

A draught of sulphate of magnesia and infusion of senna 
is the best purgative to administer. Tartar emetic may 
be given in ^-grain doses, with two or three grains of ni- 
trate of potash. 

When the matter is deep-seated, some tact is required, 
both to detect it, and let it out. Care should be taken not 
to cut across the milk ducts in so doing. If sinuses form, 
they must be laid open : or if they run too deeply, they 
must be treated by stimulant injections, and pressure 
with straps of adhesive plaster. To effect this last object 
properly, the straps of plaster should be so arranged as to 
make firm and equable pressure over the whole breast, 
every part of which should be thus covered except the 
wound by which the matter has been evacuated. 

In all cases of inflammation of the breast there is a 
troublesome feeling of weight and dragging. This may be 
much relieved by supporting the breast with a sling 
placed round the neck. 

Milk Fever — Symptoms. 

80. The congestion and excitement of the mam- 
mary glands after labor may give rise to a certain 
amount of sympathetic fever. This is called "milk 
fever," and generally sets in on the third day, with 
shivering, pain in the back and limbs, headache, 
quick full pulse, furred tongue, and feverishness, 
followed by profuse sweats, after which the febrile 
excitement subsides. The breasts are swollen, 
hard, and painful. There is an absence of abdomi- 
nal tenderness, and a copious secretion of milk ; 
two features which distinguish this complaint from 
more dangerous fevers. 

[Headache is always present, rarely noticed in 
approaching puerperal peritonitis.] 



REQUIRING A CONSULTATION. 115 

When the fever is at its height, there is sometimes 
slight delirium. 

Milk fever is. cceteris paribus, more common in primi- 
para? than in multipara}, and is much more likely to happen 
when the application of the child to the breast has been 
deferred too long. 

Treatment of Milk Fever. 

81. In the treatment of milk fever the patient 
should be kept on low diet, and should take ape- 
rients and saline diaphoretics. The ordinary dose 
of castor oil may be somewhat increased, and re- 
peated, if necessary- The distended breasts must 
be relieved by early and frequent applications of 
the child, or, if necessary, by the breast-pump. 

The following mixture may be given : — ■ 

R. — Yin. ipecac, 

Spt. seth. nit., aa ^j. 

Sodas et potassoe tart., gj. 

Aq. camph. ad 3 viij. 
M. ft. mist, cujus sumat sex tarn partem ter die. 

[Early attention to the breasts will very frequently ob- 
viate the necessity of medical interference.] 

Ephemeral Fever. 

82. Women, after delivery, are liable to a transi- 
tory fever, which has been named ephemeral fever, 
or (by the Germans) Weid. It may be brought on 
by fatigue, exposure to cold, or indigestion. Like 
an intermittent, it has a hot, a cold, and a sweat- 
ing stage. The first is characterized by shivering, 
headache, and pains in the back and limbs ; the 



11 G CASES NOT USUALLY 

second, by quick pulse, furred tongue, and fever ; 
and the third, b}^ profuse sweats, and cessation of 
fever. The whole attack seldom exceeds twenty- 
four, or at most forty-eight hours. The bowels are 
usually costive, and the milk and lochia diminished 
or temporarily suspended. This complaint is dis- 
tinguished from puerperal fever by its paroxysmal 
character, and by the absence of marked abdominal 
tenderness. 

Ephemeral fever most commonly attacks those whose 
health is somewhat impaired by a residence in low marshy 
districts. 

Ephemeral Fever — Treatment. 

83. During the cold stage of ephemeral fever, 
warmth should be applied to the surface, and warm 
drinks administered. During the hot stage, diapho- 
retics, such as Dover's powder, are indicated ; and 
also smart purges of salts and senna. An emetic of 
gr. v of ipecacuanha, at this stage, will sometimes 
serve to cut short the attack. After the fever is 
over, quinine should be given, especially if the 
attack seems at all likely to recur. 

["Keep up the perspiratory stage till the head- 
ache is removed."] 

Miliary Fever. 

84. Miliary fever is another affection occasion- 
ally met with after delivery. It is characterized 
by an eruption of very fine vesicles, about the size 
of a millet seed, and densely crowded together. It 



REQUIRING A CONSULTATION. 1 L 7 

comes on two or three days after labor, with rigors, 
followed by fever and profuse perspiration. There 
is much headache, and oppression at the praecordia. 
The tongue is furred, with the papillae red and 
prominent. The lochial discharge and milk are 
scanty. After a time the eruption comes out, hav- 
ing been preceded by tingling of the skin and copi- 
ous perspirations. It subsides after two or three 
days. This fever is distinguished from others by 
the peculiar eruption. 

As the eruption recedes, the vesicles dry up, and the 
cuticle falls off in branny scales. 

Miliary fever is most frequently met with in patients 
who have been kept in close, ill-ventilated rooms, with a 
large fire, and too much bedclothes upon them. 

Miliary Fever — Treatment, 

85. Ventilation is of great importance in the 
treatment of miliary fever. The room should be 
kept cool, and some of the bedclothes removed ; at 
the same time, every care must be taken to avoid 
sudden exposure to cold. Cooling aperients should 
be given, and afterwards tonics and astringents. 

The following aperient is a suitable one: — 
R. — Magnes. sulph., gss. 

Infus. rosse (comp.) §vj.* 
M. Capt. sext. part, sexta quaque hora. 

As a tonic, the following mixture : — 
R. — Tiuct. cinchona? co., giij. 

Acid, sulph. arom. gss. 

Aquam ad §vj. 
M. Capt. sext. part, bis die. 

* [Acid.] 



PART III. 

CASES IN WHICH THE STUDENT OUGHT TO 
SEND FOR ASSISTANCE. 



Abortion — Non-expulsion of the entire Ovum. 

1. When abortion has taken place, and the pla- 
centa, or any other portion of the ovum, remains 
behind in the uterus, give ergot, and make cautious 
attempts to bring it away with the finger. If you 
do not succeed, send for assistance. 

When the remainder of the ovum cannot be removed in 
the way just mentioned, the case is one of some difficulty, 
and requires delicacy of manipulation. The introduction 
of the hand, or of some instrument for the purpose, will 
probably be necessary. If the placenta is allowed to re- 
main in the uterus it may cause secondary hemorrhage 
(see 68, Part II.), or decompose and produce uterine 
phlebitis from absorption of putrid matter. 

Abortion with Profuse Hemorrhage. 

2. In cases of abortion accompanied with pro- 
fuse hemorrhage, before sending, apply cold, as 
directed in 55, Part II. Give a full dose of ergot, 
and plug the vagina. 



CASES REQUIRING CONSULTATION. 119 

A hemorrhage is profuse when it produces marked con- 
stitutional symptoms, such as those described in 53, Part 
II. Cases of miscarriage, under such circumstances, are 
attended with considerable risk. 

The plug, or " tampon," is a powerful means of arresting 
hemorrhage in certain conditions of the uterus. By its 
presence it stimulates that organ to contraction, and also 
exerts a pressure upon the bleeding vessels. As a general 
rule, the plug should not be used, under the circumstances 
above mentioned, after the period of quickening. Before 
that period the uterus is incapable of containing any large 
amount of blood ; but after that time there would be con- 
siderable danger of internal hemorrhage. 

For the purpose of plugging the vagina, tow, lint, or 
pieces of sponge may be used. These must be gradually 
introduced with the finger, until the vagina is completely 
filled. A soft silk or cambric handkerchief makes a very 
good plug, and should be introduced into the vagina, be- 
ginning with one of the corners. The plug should not 
be left in the vagina more than twelve hours, because 
the retained blood and discharges putrefy and become a 
source of irritation. 

If a large speculum is at hand, the plug may be intro- 
duced through it with much more ease and much less dis- 
comfort to the patient. 

Extra-uterine Foetation — Rupture of the Cyst. 

3. In cases of suspected extra-uterine foetation, 
when certain symptoms set in which indicate a 
rupture of the cyst. These are — sudden and acute 
pain in one iliac region, followed by great exhaus- 
tion, vomiting, and symptoms of internal hemor- 
rhage. Before sending, place the patient in the 
horizontal posture, apply a binder round the ab- 
domen, and cold to the part. If there is severe 
collapse, give stimulants. 



120 CASES REQUIRING CONSULTATION. 

In extra-uterine foetation the impregnated ovum, from 
some cause or other, does not reach the uterus, but is de- 
veloped externally to it, either in the ovary, the Fallopian 
tube, or in the walls of the uterus. This curious freak of 
nature is by no means of common occurrence. The diag- 
nosis is very uncertain; most of the signs of pregnancy 
are present, but the tumor formed by the impregnated 
ovum presents itself on one side of the abdomen, usually 
the iliac fossa. Pain is frequently felt in that region, 
accompanied with vomiting. The menses, in most cases, 
continue during extra-uterine gestation. After a variable 
time the cyst containing the ovum gives way, and the 
woman dies from the sudden shock to the system, and pro- 
fuse internal hemorrhage thus occasioned. Such is the 
usual history of these cases. The cyst is generally rup- 
tured during the first half of gestation. But there are 
many instances on record of women who have survived 
both the shock and subsequent inflammation, and in whom 
the foetus has been evacuated by abscess, or retained for 
months and even years. 

Expulsion of Moles, attended with much 
Hemorrhage. 
4. In cases of mole pregnancy, when the expul- 
sion of the mole is attended with much hemorrhage, 
and when portions of it remain behind in the uterus. 
In these cases, as in an abortion, you may give 
ergot, apply cold, and use the plug, before sending 
for assistance. 

Moles are shapeless masses, which are, properly speak- 
ing, the result of conception, and consist of various de- 
generations of the ovum. In many of them scarcely any 
portion of the ovum can be traced, the mass consisting of 
semi-organized coagula and layers of fibrine. This is the 
fleshy mole. In others, the foetal coverings, especially the 
chorion, have become developed into innumerable vesicles, 
resembling bunches of grapes or currants. This is the 
hvdatid mole. When the uterus contains a mole, the 



CASES REQUIRING CONSULTATION. 121 

earlier signs of pregnancy present themselves ; but the 
latter signs, such as the "ballottement," the foetal move- 
ments, and the sounds of the foetal heart, are wanting. 
After an uncertain period the uterus expels the mole with 
all the symptoms of an abortion. The expulsion of the 
hydatid mole is attended with most risk; it is usually 
accompanied with much hemorrhage, and the mole fre- 
quently does not come away entire. "When this happens, 
the introduction of the hand may become necessary. 

Symptoms of Powerless Labor. 

5. In any case of difficult labor, or otherwise, 
when symptoms of powerless labor begin to show 
themselves. These are — diminished frequency and 
force of the pains, considerable acceleration of the 
pulse between the pains, severe rigors and vomiting, 
restlessness, dry, furred tongue, retention of urine, 
heat and tenderness of the vagina, with brownish 
and occasionally fetid discharge. 

Powerless labor is always the result of a prolonged 
second stage, whether it be from obstruction of the head, 
or from inefficient uterine efforts. There is no precise 
period at which the unfavorable symptoms set in, but. in 
general, they are likely to do so after the second stage has 
lasted twelve hours. Xo prudent practitioner would allow 
such symptoms to become developed ; but. taking alarm 
at their first onset, would proceed to assist nature by art. 

[With the above symptoms the labor must be terminated. 
The forceps will save the mother's life, and probably that 
of the child.] 

The pains in powerless labor lose the forcing character 
of the second stage, and bear more resemblance to those 
of the first. The pulse may range from 100 to 130, or 
even to 140. between the pains. 

If the above symptoms are allowed to continue unre- 
lieved, the condition of the patient becomes much worse; 
the tongue is dry and brown, sordes collect about the 
11 



122 CASES REQUIRING CONSULTATION. 

teeth, the pulse is very rapid and weak ; the matter ejected 
by vomiting is dark, sometimes consisting of grumous 
blood ; the abdomen becomes tender, the surface cold and 
clammy; the restlessness passes on to jactitation, delirium, 
and death. 

Minute or Imperforate Os Uteri. 
6. When labor is obstructed by a minute or im- 
perforate os uteri, which is the result of structural 
change, and which does not yield to time and the 
usual remedies for an un dilatable os uteri. (See 
12, Part II.) 

This condition of the os uteri may be caused by cica- 
trices resulting from mechanical injuries, by inflammation, 
or by scirrhus deposit in the part. In some cases there 
is complete agglutination of the os uteri. The inferior 
portion of the uterus becomes very tense, and is forced 
down low into the pelvis with each pain ; but the finger 
in examining can detect merely a depression, and no 
opening in the part. In some rare instances, a circular 
portion of the inferior part of the uterus has yielded to 
the force of the pains, and separated so as to allow the 
child to pass. In others, it has been necessary to make a 
crucial incision in the part before delivery could be accom- 
plished. 

[Better than the crucial incision is the plan of Moscati, 
who recommends a number of small incisions around the 
os, thus securing equable dilatation. Unless the obstruc- 
tion is removed — the os rendered dilatable — a ruptured 
uterus would be the result.] 

Strictures of Vagina. 

T. When labor is obstructed by strictures of the 
vaginal canal, produced by structural alterations, 
such as cicatrices, callosities, adhesions, etc., which 



CASES REQUIRING CONSULTATION. 123 

do not yield to time and the usual remedies for 
rigidity of the soft parts. (See 16, Fart II.) 

These structural lesions of the vagina are nearly always 
the result of sloughing, and loss of substance, produced 
by a previous hard labor. The cicatrices may form rings, 
•or spirals, around various parts of the vagina, or there 
may be a partial or complete occlusion of some part of 
the canal. The cicatrices are sometimes gristly and semi- 
cartilaginous. It may be necessary to divide them with 
the knife, or even to lessen the size of the child's head by 
craniotomy. Such operations of course require a consul- 
tation. 

[A rigid hymen may obstruct the vaginal canal, im- 
pregnation being possible without injury to this band.] 

[Since writing the above I have been called to attend a 
primiparous case, in which the hymen was so tense and 
rigid that the progress of the foetal head downwards and 
forwards caused such great pain that I was obliged to cut 
out the hymen entirely.] 

Obstructed Labor from Pelvic Tumors. 

8. When labor is obstructed by tumors of various 

kinds within the pelvis, and the difficulty appears 

to be insuperable by the natural efforts. 

The tumors may be either within or without the vagina, 
and may grow from the mucous membrane of the uterus 
and vagina, or from the exterior of the uterus, its append- 
ages, or other contents of the pelvis. When these tumors 
are outside the vagina, they are usually met with in the 
cul-de-sac of the peritoneum between the vagina and rec- 
tum, where they produce a bulging of the posterior wall 
of the vagina. The tumors may be solid growths, such as 
polypi, fibrous, fatty, sarcomatous, and scirrhous masses, 
or cysts containing fluid, such as ovarian -tumors, etc. 
Sometimes a hernia a descends into the vagina during labor. 
The intestine comes down into the cul-de-sac between the 
vagina and rectum, and forms a tumor covered by the 
posterior wall of the vagina. In some rare instances, the 



124 CASES REQUIRING CONSULTATION. 

bladder contains a calculus, which descends before the 
head, during labor. The tumor thus formed is covered by 
the upper wall of the vagina like a vaginal cystocele, but is 
firm and hard, and not soft and fluctuating. 

The chief danger from calculus is not so much from the 
obstacle which it presents, as from the injury which it may 
inflict upon the bladder, when it becomes compressed be- 
tween the head and the pubis. In most cases, it is possible 
to push the calculus above the pelvic brim; but if this 
should be impracticable, vaginal lithotomy may be neces- 
sary. In short, in all cases of pelvic tumors, the treat- 
ment must depend very much on the circumstances of the 
case ; some tumors are movable, and may be pushed above 
the head ; others, such as polypi, etc., admit of excision ; 
others, such as ovarian tumors, may be tapped. All these 
operations, except the first, are attended with risk, and 
require much judgment. If any such operation be im- 
practicable, delivery with the forceps or craniotomy may 
be required. 

Prolapse of Bladder during Labor. 

9. When there is a prolapse of the bladder during 
labor. In such cases the bladder descends before 
the head, and forms a fluctuating tumor, covered 
by the upper wall of the vagina. The finger readily 
passes beneath and behind the tumor, until it 
reaches the head. Before sending, evacuate the 
bladder, if possible, by passing a gum-elastic cathe- 
ter with the point directed downwards and back- 
wards. 

Prolapse of the bladder, or vaginal cystocele, is a rare 
complaint. It is occasioned by a relaxation of the upper 
wall of the vagina, and other connections of the bladder. 
The symptoms are — fulness, tension, and dragging, with 
a constant desire to pass water, and much difficulty in 
doing so. If there has been complete retention of urine 



CASES REQUIRING CONSULTATION. 125 

for some time, there is considerable risk that the pressure 
of the head may cause a rapture of the bladder. 

Difficult Labor from Pelvic Deformity — 
Diagnosis* 

10. When labor is obstructed in the second stage 
by pelvic deformity. In these cases, the head is 
arrested in its progress at some particular part of 
the pelvis (generally the brim), and remains im- 
movable, notwithstanding there may have been 
strong forcing pains for some hours. The scalp 
becomes very tumid, and the bones overlap very 
much, so as to give the vertex a conical shape. 
You need not be in a hurry to send for assistance 
in such cases (see 42, Part II.); but you must do 
so without delay if there be the least symptom of 
powerless labor, or if the head become impacted, 
i. e.j so firmly fixed that it cannot recede between 
the pains, and can only be displaced with great 
difficulty. 

Deformities of the pelvis are occasioned by rickets 
during childhood, mollities ossium in adult age, bony 
growths, fractures, etc. The deformity may affect the 
brim, cavity, or outlet of the pelvis. The brim is most 
usually affected, and the most ordinary kind of deformity 
is a prominent sacrum, causing a diminution of the antero- 
posterior diameter of the brim. The pelvis in such cases 
becomes heart-shaped. 

The degree of deformity may vary very much, but it is 
most readily estimated by measuring the antero-posterior 
diameter of the brim. This may be done by introducing 
the tips of four fingers of one hand in a line, between the 
sacral promontory and pubis. If they cannot be separated, 
for instance, there is much deformity; but if they can be 
11* 



196 CASES REQUIRING CONSULTATION. 

separated widely, there is little or none. Again, if the 
forefinger, during an ordinary examination, impinges on 
the upper part of the sacrum, we have reason to believe 
that the deformity is considerable. 

The existence of pelvic deformity may also be ascer- 
tained by the great difficulty which is experienced in pass- 
ing up the forefinger between the head and the different 
parts of the pelvis. Distortions of the cavity and outlet of 
the pelvis are not so common; they generally depend on 
unnatural straightness of the sacrum, approximation of 
the tubera ischii, narrowing of the pubic arch, or anchy- 
losis of the coccyx, etc. They produce much the same 
symptoms as distortions of the brim, except that they 
arise at a later period of the labor. 

The symptoms occasioned by deformity of the brim have 
been very accurately described by Dr. Rigby. " Besides 
the general appearance of the patient," he says, " we fre- 
quently find that the uterine contractions are very irregu- 
lar; that they have but little effect in dilating the os uteri: 
the head does not descend against it, but remains high up ; 
it shows no disposition to enter the pelvic cavity, and 
rests upon the symphysis pubis, against which it presses 
very forcibly, being; pushed forwards by the promontory 
of the sacrum." When the deformity is not very consider- 
able, it often happens that after some hours of severe pain, 
the difficulty is suddenly overcome, the head passes, and 
the rest of the labor is speedily accomplished. 

When, however, the deformity is more considerable, the 
forceps is likely to be required ; when it is still greater, 
the accoucheur is reduced to the painful necessity of de- 
stroying the child by craniotomy. Again, where the dis- 
tortion is extreme, delivery per vias naturales becomes 
impossible. The Cesarean section is then the last resource 
of art. 

The forceps is inadmissible when the antero-posterior 
diameter of the pelvis is less than three inches; because it 
has been laid down as a rule, that a living child cannot 
pass through a pelvis of such dimensions. Craniotomy, 
or the cephalatribe, may be employed when the antero- 
posterior diameter is not more than three inches, nor less 
than an inch and a half. When it is less than an inch and 
a half, delivery per vias naturales is scarcely possible. 



CASES REQUIRING CONSULTATION. 127 

Impaction of the bead is always attended with consider- 
able danger. The constant and severe pressure upon the 
soft parts lining the pelvis will almost certainly produce 
inflammation and sloughing of those parts. Hence, there 
is a necessity for prompt interference. 

Arrest of Head in Cavity of Pelvis. 

11. When the head is arrested, either in the 
cavity or outlet of the pelvis, in consequence of 
some want of power in the uterus, and also some 
slight disproportion between the head and pelvis. 
The time when you ought to send must depend 
very much upon the state of the patient; but, as 
a general rule, you ought to do so before the head 
has been arrested as long as four hours. 

In the preceding case the use of the short forceps is in- 
dicated. Ergot of rye is inadmissible, because there is 
a mechanical Obstacle to delivery, as well as a want of 
power. 

Unless the condition of the patient be such as to require 
interference, the forceps should not be used whilst the 
pains continue regular, and the head advances ever so 
little. 

Cases in which no Presentation can be felt. 

12. In the first stage of labor, when the os uteri 
is dilated to the size of a crown-piece, or even 
larger, and no presentation can be detected, al- 
though you have made a careful examination with 
both hands. 

When no presentation can be felt, although the os uteri 
is widely dilated there is in all probability what nurses 
call a "cross birth," i. e., the long axis of the child is at 



128 CASES REQUIRING CONSULTATION. 

right angles with the axis of the pelvis, the shoulder or 
arm presenting. 

AVhen the child is in this position, the presentation sel- 
dom descends sufficiently low to be felt at any early period 
of the labor. In such cases the greatest care is necessary 
in examining, lest the membranes be ruptured ; because, as 
turning will in all probability be required, the escape of 
the liquor amnii would render that operation very difficult. 

The presentation may also remain out of reach in a 
similar manner when the pelvis is deformed, or the child's 
head hydrocephalic. 

Gases of Brow Presentation. 

13. In cases of brow presentation. These unfa- 
vorable presentations of the head are recognized 
by the facility with which you can reach the great 

T\s. 13. 




fontanelle and also the upper part of the face, the 
one being turned towards one side of the pelvis, 



CASES REQUIRING CONSULTATION. 129 

and the other towards the opposite side, the pre- 
senting part being one of the frontal eminences. 
(Fig. 14.) 

Fig. 14. 




Presentations of the brow are intermediate between 
those of the vertex and those of the face, approaching, 
however, more nearly to the latter than the former. When 
the vertex presents, the head is said to be flexed upon the 
body, so that the chin is close to the chest (Fig. 13) ; when 
the face presents, the head is extended completely, and 
the chin is as far removed from the chest as the neck will 
admit of (Fig. 15). In a brow presentation the head is par- 
tially extended, so that one of the frontal bones presents, 
most commonly either the right or left frontal eminence 
(Fig. 14) . At the commencement of labor, the presenting 
part may be included in a circle, the circumference of 
which touches the root of the nose on one side, and the 
great fontanelle on the other. On examining at this stage 
of the labor, the face would be found usually looking to- 
wards one sacro-iliac synchondrosis, and the great fon- 
tanelle towards the acetabulum of the opposite side, or 
vice versa. As the head descends lower, and becomes 



130 CASES REQUIRING CONSULTATION. 

more fully engaged in the pelvis, the mento-occipital dia- 
meter will correspond with one of the oblique diameters of 
the pelvis, and thus will take a position nearly at right 
angles to that which it occupies in an ordinary case; for 

Fi<?. 3 5. 




then it is parallel to the axis of the pelvic brim, and is 
perpendicular to these diameters. In a brow presentation 
the head is placed in the most unfavorable manner possi- 
ble for traversing the brim of the pelvis ; for the longest 
diameter of the head (the occipito-mental, which measures 
five inches) corresponds with the oblique diameter of the 
pelvic brim, measuring only four inches and a half. [The 
occipito-mental diameter of the foetal head, as given by 
Dr. Meigs, is five and a half inches. Dr. J. K. Yan Pelt, 
who measured seven hundred foetal heads, places this 
diameter at 5£$. Dr. Addinell Hewson, who measured 
one hundred and sixty-six, puts it at 5.25. Thus showing, 
what I have before remarked, that the foetal heads in this 
country are larger than those of foreign lands.' Dr. Meigs 
places the occipitofrontal diameter at 4}| and biparietal 
3J|-.] It is, therefore, scarcely possible for the head to 
traverse the pelvis in this position ; and it will be found, 
as a general rule, that manual interference is necessary in 



CASES REQUIRING CONSULTATION. 131 

the treatment of these cases. The forehead may be pushed 
up, or the chin brought down, so as to convert it into 
either a vertex or a face presentation. Any attempts to 
effect the first will probably prove unsuccessful, but the 
last may readily be accomplished either by the fingers or 
the vectis. 

Arrest of Child's Body in Breech Presentations. 

14. In breech presentations, when the breech is 

arrested in the cavity of the pelvis, from want of 

room or from insufficient uterine action. 

The rules which are applicable in cases of arrest of the 
head (see 11, Part III.) respecting the time to send for 
assistance, will also apply to breech cases. When the 
breech is arrested, it may be necessary to assist the de- 
livery. This is usually done by hooking the finger over 
the groin, and making traction in concert with the pains. 
Some recommend a blunt hook for this purpose, whilst 
others advise the use of the forceps. Without much care 
the first of these instruments would be likely to inflict in- 
jury on the child; and the same may be said of the se- 
cond, which is indeed scarcely suitable for breech cases. 

Arrest of Head in Breech Presentations. 

15. In breech presentations, when the head is 
arrested at the brim of the pelvis, and cannot be 
brought through by rectifying its position and 
making cautious and steady traction by the neck. 

In these cases there is generally some want of room in 
the pelvic brim. The forceps has been recommended, but 
its utility is very questionable. The child is almost sure 
to be dead from pressure on the cord, and the best plan 
then is to lessen the size of the head by opening it behind 
the ear, and evacuating the brain. 

[If the forceps can be applied, it is best that an attempt 
to use them should be made before entering upon so ter- 
rible an operation as craniotomy.] 



132 CASES REQUIRING CONSULTATION. 

Presentations of Superior* Extremities — Diagnosis. 

16. In presentations of the superior extremity, 
i. e., either the shoulder, elbow, or hand. These 
occur about once in 231 cases. The shoulder is 
known by its being more pointed than either the 
head or the breech. You recognize it by feeling 
the clavicle and spine and acromion process of the 

Fig. 16. 




scapula; and, above all, by the ribs, which will at 
once distinguish it from any other part of the 



CASES REQUIRING CONSULTATION. 133 

body. For characteristics of the elbow, see 31, 
Part II. ; and of the hand, see 30, Part II. 

When the superior extremities present, the child is 
placed transversely with regard to the pelvis. Delivery 
ill this position is almost impossible, but still may take 
place in rare exceptional instances, by a natural process 
of expulsion, to which the name " spontaneous evolution" 
has been given. Such an unusual occurrence should 
never be depended on in practice. The presentation 
should be altered by turning the child, and bringing down 
the feet. 

Assistance should be sent for immediately, as soon as 
a presentation of the superior extremities is detected. 
Too much care cannot be taken lest the membranes be 
ruptured by injudicious examinations. 

In shoulder presentations the hand and arm usually 
prolapse after the rupture of the membranes, and remove 
all doubt, if any existed before, as to the nature of the 
presentation. 

[The membranes unbroken, it is comparatively an easy 
matter to turn the child, but if the liquor amnii has es- 
caped, it is sometimes very difficult.] 

Monsters. 

17. When labor is obstructed, in consequence of 
abnormal development or monstrosity of the foetus. 

Extraordinary size of the foetus, or unusual ossification 
of its head, may act as a cause of difficult labor, and ren- 
der the use of the forceps necessary. 

Monsters are of two kinds, viz., monsters by deficiency, 
and by excess. The former class will be puzzling as re- 
gards diagnosis, but present no difficulties as to delivery. 
The latter class, however, may occasion obstacles of a 
serious kind ; in most cases, various parts of two (or 
more) children are united together. The treatment 
must depend very much upon the circumstances of each 
case. When there is much difficulty, turning, or embry- 
12 



134 CASES REQUIRING CONSULTATION. 

otomy, may be required ; or, perhaps, both these opera- 
tions. 

Hydrocephalus or Ascites of Foetus — Diagnosis. 

18. When labor is obstructed, in consequence of 
increased size of the child's head from hydro- 
cephalus, or of its abdomen from ascites. Hydro- 
cephalus is distinguished by the very large size of 
the head, which occupies the entire contour of the 
superior strait of the pelvis. The head is resist- 
ing during a contraction, and soft and fluctuating 
in the intervals of pain. The sutures (especially 
the sagittal) and fontanelles are unusually open, 
and the cranial bones are widely separated from 
one another. Ascites is distinguished by the 
large size of the abdomen, and the distinct sense 
of fluctuation which it communicates to the finger. 

In either of these cases, the increased size of the child's 
head, or body, may occasion a train of symptoms similar 
to those which arise in the course of a difficult labor, 
from diminished size of the pelvis. 

When the bones are widely separated, the tips of the 
fingers may be passed between, and even slightly beneath 
them. 

Hydrocephalic infants may be expelled by the natural 
powers, provided the pelvis is roomy; but the labor is 
usually very tedious and difficult. In most cases assist- 
ance will be required ; the size of the head must be less- 
ened by puncturing it with a small trocar, in one of the 
sutures, and letting out the fluid. The abdomen may be 
tapped, in a similar way, in ascites. 



CASES REQUIRING CONSULTATION. 135 

Prolapse of Umbilical Cord — Diagnosis. 

19. When there is a prolapse of the umbilical 
cord during labor. In this case (which happens 
about once in 221 labors), before the membranes 
rupture, 3^011 may feel through them a small, soft, 
movable body, which may be readily displaced, 
and has a rapid pulsation, isochronous with the 
foetal heart. After the membranes have ruptured, 
the diagnosis is very easy; for the cord can 
readily be felt in the vagina. Sometimes it is pro- 
lapsed beyond the os externum. As soon as you 
have ascertained the existence of this complication, 
you must send for assistance without delay, having 
previously placed the woman on her hands and 
knees ; but if you find that the cord is quite 
destitute of pulsation, you may let the labor take 
its course. 

A prolapse of the funis does not make any difference 
in the course of a labor as regards the mother ; but it is 
a complication fraught with the utmost danger to the 
child. If a prolapsed cord cannot be reduced, the child 
will almost inevitably die before the termination of the 
labor, from pressure on the umbilical vessels. There are 
several causes which may produce this accident, such as 
unfavorable presentations, irregularity in the shape of the 
pelvis, sudden escape of a large quantity of liquor amnii, 
excessive length of cord, 1 low insertion of the cord into 
the placenta, or attachment of the placenta to the neck 
of the uterus, etc. 

When the cord can be felt distinctly pulsating, some 



1 In a case occurring in the author's practice, the cord 
measured five feet in length. 



136 CASES REQUIRING CONSULTATION. 

interference is necessary to save the life of the child, pro- 
vided that the os uteri is sufficiently dilated to allow it. 
Various means have been devised for reducing the cord 
and keeping* it up out of the way, until the presenting 
part has descended and fully occupied the pelvic cavity. 
One of the best of these is the postural method just 
mentioned. In this position, on the hands and knees, the 
cord naturally gravitates towards the fundus uteri. If 
these devices fail, turning will be necessary. If the labor 
be too far advanced for turning, the forceps may be used. 
When the cord is cold and pulseless, the child is dead. 
There is, therefore, no necessity for interference. 

Accidental Hemorrhage — Diagnosis. 

20. In cases of accidental hemorrhage, i. e. hem- 
orrhage arising before birth from a casual detach- 
ment of part of the placenta. This hemorrhage 
comes on shortly before or at the full term, of 
pregnancy, and is generally the result of some 
sudden shock, either mental or bodily. It com- 
mences with dull pain and aching in the belly and 
back. The uterus feels firmer, tenser, and percep- 
tibly larger than before. After a time the usual 
symptoms of hemorrhage supervene (see 53, Part 
II.), and, in most cases, fluid blood and coagula 
escape externally. The os uteri is soft and dilata- 
ble. If you pass your finger within it, and around 
its circumference, you feel the smooth bag of the 
waters presenting. If labor-pains are present, the 
hemorrhage is arrested during the pains, but re- 
turns in the interval ; whereas the exact converse 
takes place in unavoidable hemorrhage. 

The detachment of the placenta is mostly partial ; but 



CASES REQUIRING CONSULTATION. 137 

in some exceptional cases the placenta is wholly detached. 
Again, the hemorrhage may be entirely internal. The 
hemorrhage may be a result of general plethora, as well 
as of any sudden shock, such as coughing, sneezing, 
vomiting, over-exertion, blows, falls, etc. 

When the os uteri is smooth and regular throughout 
its entire circumference, aud the membranes can be felt 
presenting, we may be sure that the hemorrhage is not 
occasioned by placenta previa, especially if it cease 
during the pains. The hemorrhage is arrested during a 
pain, because the bleeding vessels are compressed by the 
contracting fibres of the uterus. 

Treatment of Accidental Hemorrhage. 

21. As soon as you have sent for assistance, you 
must take some means to check the hemorrhage. 
If the term of pregnancy has not expired, if the 
hemorrhage be not profuse, if there be no pains, 
and little or no dilatation of the os uteri, place the 
woman in the recumbent posture, and let her be 
kept cool and quiet. Apply cold compresses to 
the abdomen and vulva, give cold drinks, and use 
enemata of cold water. Also administer astrin- 
gents and sedatives. But, if labor-pains have set 
in, if the os uteri be dilated, and the hemorrhage 
severe, you must use, in addition, measures which 
will increase uterine contraction, such as the ad- 
ministration of ergot and the application of the 
binder. If these fail, you may rupture the mem- 
branes. 

If the term of pregnancy be not completed, we may 
hope, in some instances, to restrain the hemorrhage, and 
conduct the woman safely to the full time. 

The following mixture may be given : — 
12* 



138 CASES REQUIRING CONSULTATION. 

R. — Acid sulph. dil., 3j. 
Tinct. opii, rcixl. 
Infus. rosae acid, ad ,^vj. 
M. ft. mistura, cujus sumat sextam partem omni hora. 

Or the following : — 

R. — Plumbi acetat., gr. xviij. 

Acid, acetic, n\xx. 

Morphiae acetat., gr. j. 

Aq. destillat., gvj. 
M. capt. sextam partem secunda quaque hora. 

A plug has been much recommended in these cases ; 
but it is a hazardous remedy, especially in the hands of 
an inexperienced practitioner. 

Rupturing the membranes is one of the surest means 
both for restraining hemorrhage and forwarding the labor. 
"When the liquor amnii has escaped, the uterus contracts 
firmly around the body of the child, at the same time 
compressing the placenta and closing the bleeding vessels. 
It should, however, only be adopted by the student as a 
last resource, because it may possibly fail, and the result 
would be that the operation of turning, which might be 
required, would be thus rendered difficult. 

Placenta prssvia — Diagnosis. 

22. In cases of unavoidable hemorrhage. In 
these, the placenta is attached over the os uteri ; 
and the necessary result is that, as soon as the os 
begins to open, the placenta becomes detached, 
and a copious hemorrhage takes place. The flood- 
ing usually comes on a few weeks before delivery, 
and is at first inconsiderable. After a week or 
two it returns more copiously, until, at last, it be- 
comes frequent and profuse. The flooding accom- 
panies each uterine contraction, and ceases in the 
intervals between them. On examining, you either 



CASES REQUIRING CONSULTATION. 139 

find that the entire os uteri is thickened, and occu- 
pied by the firm, rough, spongy mass of the pla- 
centa, or 3'on find that the os is partly occupied 
b}^ the placenta and partly by the membranes. 
The first is a complete, and the second a partial, 
presentation of the placenta. 

The hemorrhage from placenta praevia is occasioned, 
first, by the slight dilatation of the cervix uteri, which 
takes place some weeks before delivery ; and subsequently, 
by the still further dilatation which is effected during 
labor. The opening of the cervix produces a disruption 
of the connections between the placenta and uterus ; the 
large venous sinuses of the latter are laid open, and fright- 
ful hemorrhage ensues, which increases pari passu with 
the pains. 

Placenta pra^via is the most dangerous of all presen- 
tations. If labor be permitted to go on under such cir- 
cumstances without interference, the woman will almost 
certainly bleed to death before its termination. Still, 
however, a few exceptional cases occur in which nature 
effects delivery without a fatal result. In these the ute- 
rine contractions are very powerful and energetic. The 
placenta speedily becomes detached and expelled, and the 
hemorrhage ceases. As soon as the placenta is completely 
detached the uterine arteries are broken away from it, 
and the veins are closed by the dilation of the os uteri 
which effected the separation, as well as by the direct 
compression of the child's head, which soon descends and 
occupies the place of the placenta. 

Placenta preevia — Treatment. 

23. In cases of placenta praevia send immediately 
for assistance, and try to arrest the hemorrhage 
by placing the woman in the recumbent posture, 
by cold applications to the abdomen and vulva, 
by cold drinks and enemata, and by repeated doses 



140 CASES REQUIRING CONSULTATION. 

of opium. If the full term has not yet arrived, 
these means may for a time succeed. If they 
should fail, you may plug the vagina until assist- 
ance arrives. If there is a partial placenta presen- 
tation, you may rupture the membranes, as in ac- 
cidental hemorrhage. In all cases stimuli are to 
be given, if necessary. 

In cases of complete placenta presentation, the proper 
treatment is to turn and deliver as soon as the os uteri is 
sufficiently dilatable to allow of such a proceeding. In 
some instances, where the exhaustion from hemorrhage is 
very great, and when turning would be dangerous, com- 
plete detachment of the placenta has been recommended, 
and practised with success. (See Sir J. Simpson's memoirs 
on this subject.) Should the inferior extremities present 
with placenta praevia, it is a fortunate circumstance, be- 
cause there will be no need of turning. 

When the membranes have been ruptured in partial 
placenta praevia the head descends, compresses the pla- 
centa and the bleeding vessels of the uterus, and thus 
stays the hemorrhage. 

Puerperal Convulsions ; Epileptic Form — 
Symptoms. 

24. In all cases of puerperal convulsions. These 
usually assume the form of epilepsy, and may su- 
pervene before, during, or after labor. They are 
generally preceded by headache, drowsiness, ob- 
scure vision, and tinnitus aurium. As the fit 
comes on the woman loses consciousness, the pu- 
pils become dilated, and the countenance rigid. 
All the mucles of the body are seized with violent 
spasmodic contractions; the face is livid and hor- 
ribly distorted, the respiration hissing, the tongue 



CASES REQUIRING CONSULTATION. 141 

is thrust out, and a bloody foam issues from the 
mouth. After a few minutes the fit passes off, 
and returns again in half an hour, an hour, or 
more. According to the severity of the case, con- 
sciousness may be completely, partially, or not at 
all, regained during the intervals. 

The muscular contractions during the paroxysms are so 
violent that the attendants often have the greatest diffi- 
culty in keeping the patient upon the bed. The tongue 
being thrust out, it is very liable to be bitten, in conse- 
quence of the contractions of the muscles of the jaw. 
Hence it is that the saliva is so apt to be tinged with 
blood. The urine and feces are often expelled involun- 
tarily during the convulsions. The progress of labor, 
although in some degree interfered with, is not arrested 
by the convulsions. The fits are apt to recur simultane- 
ously with the pains, and the child may be born during 
one of these paroxysms. Under such circumstances it is 
very likely to be dead, or to die soon after its birth. 

In bad cases the breathing remains stertorous, and the 
patient lies in a comatose state between the fits. 

Epileptic convulsions may occur in very opposite con- 
ditions of the circulating system. In most cases they 
appear to be connected with a state of hyperemia. In 
some few instances they have been noticed in connection 
with extreme anaemia, from flooding. In by far the greater 
number, a state of toxaemia has been recognized by the 
presence of albumen in the urine. It must be obvious 
that diametrically opposite principles of treatment would 
apply to the first and second class of cases. 

Hysterical and Apoplectic Convulsions — Diagnosis. 

25. Besides the epileptic form of convulsions, 
there are the hysterical and apoplectic. These 
are distinguished from the first bv the following 
marks : The hysterical convulsions usually come 



142 CASES REQUIRING CONSULTATION. 

on during the early months of pregnancy, and re- 
semble ordinary hysterical paroxysms, being unac- 
companied with complete loss of consciousness, 
distortion of the face, or foaming of the mouth. 
After the attack is over the patient resumes her 
ordinary condition. Apoplectic convulsions mostly 
come on during the second stage of labor, and re- 
semble a severe attack of apoplexy; the convul- 
sion shows no disposition to return, and is speedily 
followed by stertorous breathing, and complete 
loss of thought, sensation, and voluntary motion, 
until, at last, all muscular action ceases. 

Hysterical convulsions most commonly happen about 
the time of quickening. They require very different treat- 
ment from that which is needed in the other two kinds, 
and are of far less serious import. 

Apoplectic convulsions are almost invariably fatal, and, 
in general, depend upon a sudden rupture of one of the 
cerebral vessels. In persons predisposed to apoplexy, the 
great stress upon the vessels of the brain during the second 
stage of labor, is very likely to produce such a result. 

Treatment of Convulsions. 

26. In all cases of convulsions, send for assist- 
ance immediately. In the mean time you should 
take precautions to prevent the woman from in- 
juring herself during the paroxysms. You should 
see that she does not roll off the bed, and insert a 
cork or pad of some kind between the teeth, to 
prevent her from biting her tongue. The follow- 
ing remedies may be used in all cases, viz., cold 
affusion to the head, and sinapisms to the calves 



CASES REQUIRING CONSULTATION. 143 

of the legs, together with purgatives and antir 
spasmodic enernata. 

The following enema maybe mixed with a pint of warm 
water or thin gruel, and injected into the rectum : — 

R.— 01. terebinth., 

Trae. assafcetid., aa §ss. 

Ovi vitellum, 

01. ricini, gj. M. 

The student should always request a consultation in all 
cases of puerperal convulsions, because a widely different 
treatment is required in the several forms of convulsions ; 
hence, an error in diagnosis might be attended with dan- 
gerous or even fatal results. For instance, in the epilep- 
tic and apoplectic forms, a decidedly antiphlogistic treat- 
ment is necessary, such as free venesection, leeching, 
blisters, calomel, etc. Whereas, on the contrary, stimu- 
lants, anti-spasmodics, and sedatives are indicated in 
hysterical convulsions. 

Epileptic convulsions, during labor, seem to depend 
very much upon irritation, caused by the presence of the 
foetus in utero. Delivery, therefore, becomes an important 
remedial agent, provided the labor is sufficiently ad- 
vanced to admit of it. The forceps is preferable to all 
other means of effecting delivery. In epileptiform con- 
vulsions, chloroform inhalations have been found of great 
service in restraining the fits. But, according to the au- 
thor's experience, a full dose of the hydrate of chloral by 
enema is still more effectual. 

Bupture of Uterus — Symptoms. 

21. When a rupture of the uterus takes place 
during labor. The symptoms of this alarming 
accident are, sudden and acute pain in the abdo- 
men, followed by a ghastly pallor of the counte- 
nance, weak thready pulse, syncope, constant 
vomiting of dark, grumous fluid, resembling coffee- 



144 CASES REQUIRING CONSULTATION. 

grounds, and other signs of extreme prostration. 
There is usually a discharge of blood from the 
vagina. The presentation recedes out of reach, 
and, if the rent in the uterus be large, the child 
escapes through it into the abdominal cavity, 
where its limbs may be very distinctly felt through 
the parietes. In these cases, after sending for 
assistance, you may endeavor to keep up the 
powers of life by stimuli ; but death nearly always 
takes place after a few hours. 

Rupture of the uterus is the most dangerous complica- 
tion of labor to which women are liable : it is fortunately 
rare, occurring about once in 1331 cases. It may be 
occasioned by malpresentation, deformity of the pelvis, the 
abuse of ergot, awkward attempts to turn or to use in- 
struments, structural degenerations of the uterus, etc. In 
some instances, the rupture may not extend through the 
entire thickness of the uterine parietes. When it is of 
this partial character, it is attended with less imminent 
danger. 

The vagina may be lacerated during labor at its junc- 
tion with the uterus. The symptoms produced resemble 
those of ruptured uterus, but they are not so urgent, nor 
are they attended with so much danger. 

When the uterus is ruptured, delivery should be accom- 
plished as soon as possible by turning, by the forceps, or 
by craniotomy. 

If the child has escaped into the abdominal cavity, the 
hand must be passed through the rent in the uterus in 
order to search for the feet. The foetus has been delivered 
by gastrotomy, when delivery per vices naturales has been 
found impossible. 

If the woman survive the immediate shock of the rup- 
ture, she will be likely to be carried off subsequently by 
peritonitis. Should peritonitis supervene, it must be 
treated in the usual way. 



CASES REQUIRING CONSULTATION. 145 

Inversion of Uterus — Symptoms. 

28. In cases of inversion of the uterus. This 
dangerous accident is somewhat rare. It usually 
happens very soon after the birth of the child. It 
may occur spontaneously, but much more fre- 
quently is the result of improper traction upon the 
cord when the placenta is still attached. (See 
Note 36, Part I.) The inversion may be partial, 
and limited to the fundus ; or the uterus may be 
turned completely inside out, and pass beyond the 
os externum, where it presents as a globular elastic 
tumor, with a bright-red, rough, bleeding surface. 
As the uterus descends, the woman experiences a 
sensation as if a second child were coming into 
the world, and is immediately afterwards attacked 
with vomiting, syncope, and alarming prostration, 
accompanied, not unfrequently, with profuse hem- 
orrhage. 

In complete inversion the uterus descends through the 
os uteri, until the whole organ becomes external to the 
vulva. The inverted organ then contains a cavity com- 
municating with the abdomen, and lined by peritoneum. 
Within the cavity are the uterine appendages, and occa- 
sionally the intestine. In partial inversion, the fundus 
may be merely depressed into the cavity of the uterus 
like the bottom of a glass bottle ; or the greater portion 
of the uterus may be depressed, and form a tumor within 
the vagina, but not external. When the inversion is com- 
plete, no uterine tumor whatever can be felt in the hypo- 
gastric region ; when it is partial, the depression of the 
fundus can often be felt through the parietes. 

Inversion of the uterus is always attended with much 
peril. If the displacement be not speedily reduced, the 
13 



146 CASES REQUIRING CONSULTATION. 

woman will in all probability die from the immediate shock 
of the accident, or from hemorrhage, inflammation, gan- 
grene of the uterus, etc. 

Inversion in some instances takes place spontaneously, 
in consequence of the woman making a sudden bearing- 
down effort immediately after the birth of the child. 

Treatment of Inversion of Uterus. 

29. When the uterus is inverted you should send 
for assistance, but, at the same time, you should 
make an immediate attempt to replace it. Accord- 
ingly, you compress the tumor firmly with both 
hands, and then push the fundus upwards into the 
pelvis, in the direction of the vaginal canal, by 
means of the fingers placed in the form of a cone. 
Should the placenta adhere to the uterus, it ought 
to be returned with it ; but should it be impossible 
to do so, it may be separated. After the uterus is 
returned, the hand should be kept in its cavity 
until it is expelled, with the placenta, by the uterine 
contraction. Should the first attempt at reduction 
fail, you may try again, after emptying the bladder 
and rectum. 

The reduction of an inverted uterus is comparatively 
easy provided it be done immediately after the accident. 
The chief difficulty is felt in pushing the tumor past the 
perineum ; as soon as it has passed this point, the uterus 
flies back into its proper position with a jerk. 

If the uterus has been inverted for four or five hours, 
the reduction becomes exceedingly difficult, on account of 
the strangulation and consequent swelling of the inverted 
organ. 



CASES REQUIRING CONSULTATION. 147 

Retention of Placenta — Causes and Symptoms. 

30. In cases of retention of the placenta (see 
Note 36, Part I.). This may be due to three dif- 
ferent causes, viz : 1. Torpor of the uterus. 2. 
Irregular contraction. 3. Morbid adhesion of the 
placenta to the uterus. The sj-mptoms of the first 
have already been mentioned (see 54, Part II.). 
In the second case there is a spasmodic or "hour- 
glass" contraction of some of the circular fibres, 
either of the os uteri internum (which is the most 
frequent), or of the body or fundus of the uterus. 
The cord may be traced passing through the con- 
striction. In the third case, the existence of ad- 
hesion can only be made out when the hand is 
introduced into the uterus, in order to detach the 
placenta. In all these cases there will be much 
hemorrhage, if anj' portion of the placenta be de- 
tached. 

The name " hour-glass contraction" has been given to 
irregular contraction of the uterus, because that organ 
appears to be divided into two chambers, by the circular 
construction of its fibres. The whole or only a portion of 
the placenta may be retained in the upper chamber. Ir- 
regular and spasmodic contraction of the uterus is very 
likely to ensue if the cord be dragged when the placenta 
is adherent. (See Note 36, Part I.) 

Retained Placenta — Treatment. 

31. When the placenta is retained, you must en 
deavor to excite the uterus to proper contractions 



148 CASES REQUIRING CONSULTATION. 

by pressure and friction upon its surface. When 
there is uterine inertia, ergot of rye may also be 
given, as advised in 55, Part II. When the pla- 
centa is retained by irregular contraction, you may 
give a dose of opium, and keep up for some time 
gentle but steady traction upon the cord. How- 
ever, in most of these cases, and especially when 
the placenta is morbidly adherent, the introduction 
of the hand into the uterus is the only measure 
which will suffice ; but you had better not under- 
take this without a consultation. 

When the hand is introduced into the litems, the finders 
are placed in a conical form, and gradually insinuated 
into the vagina. If there is hour-glass contraction, the 
cord serves as a guide along which the tips of the fingers 
are to be passed, until they reach the constriction. The 
tips of the fingers are then inserted into the stricture, and 
the fingers gradually and steadily expanded until they 
overcome the resistance of the circular uterine fibres. 
The hand can then be passed on into the uterine cavity, 
so as to remove the placenta. If the placenta be morbidly 
adherent, any detached portion of it should be seized, and 
the remainder gradually and cautiously separated by the 
fingers from the uterus until the whole can be removed. 
Whilst this is being done with one hand, the other hand 
should be placed externally on the abdomen, in order to 
grasp and steady the fundus uteri. These operations 
require much tact and delicacy. The introduction of the 
hand into the uterus is a measure always attended with 
some risk, but the operation becomes doubly hazardous 
when the placenta is morbidly adherent. There is then 
danger of injuring the uterus, as well as of leaving portions 
of adherent placenta behind. These operations should 
never be attempted by the student, except in extreme 
cases ; as, for instance, when there is a profuse hemor- 
rhage, and no assistance at hand. Should any portions 
of ihe placenta be left behind, they will be likely to decom- 



CASES REQUIRING CONSULTATION. 149 

pose, and occasion much irritation. To obviate these 
effects, the vagina should be syringed daily with weak 
disinfectant lotions. (See Note 67, Part II.) 

Puerperal Fever — Symptoms. 

32. In all cases of puerperal fever. These fevers 
assume various types and degrees, from the acutely 
inflammatory to the adynamic forms. From the 
inflammatory lesions, which are present in various 
cases, they have been called metro-peritonitis, hys- 
teritis, uterine phlebitis, etc. The usual period of 
invasion is the third day after delivery. The more 
prominent symptoms in all cases are rigors, fol- 
lowed by severe headache, fever, quick and often 
feeble pulse, suppression of the milk and lochia, 
pain and tenderness on pressure in the uterine re- 
gion, extending from thence over the whole abdo- 
men. The woman loses all interest in her child, 
and her countenance betokens anxiety and great 
prostration of strength. Besides these symptoms 
there are generally delirium, vomiting, tympanites 
abdominis, and sometimes diarrhoea. The disease 
nearly always ends in death after a few days. 

There have been very great differences in the classifica- 
tions of puerperal levers. Dr. Lee referred them all to 
inflammation of different parts of the uterus and uterine 
appendages. 

Dr. Ferguson believed them to depend upon a vitiation 
of the fluids from absorption of putrid matters, etc., by 
means of the inner surface of the uterus. In some of the 
worst forms of the disease no inflammatory lesions of any 
kind can be detected. 

Puerperal fever, in its worst form, is a highly contagious 
13* 



150 CASES REQUIRING CONSULTATION. 

disease, and may be readily communicated from one patient 
to another, through the medium of the medical man in 
attendance. Moreover, it has been proved, by numerous 
cases, that the disease may be produced by a variety of 
other poisons, and, above all others, by that of phleg- 
monous erysipelas. Dr. Braxton Hicks, however, refers 
the greater number to scarlatina. Fevers of different 
kinds, such as scarlet fever, or typhus, when they occur 
after delivery, will assume a very malignant form, and bear 
much resemblance to puerperal fever. It was ascertained 
in the Vienna lying-in hospital, in 1846, that puerperal 
fever could frequently be traced to examinations made by 
students who had, just before, been engaged in opening 
bodies in the dead house. It cannot, therefore, be too 
strongly impressed on the minds of students that the 
greatest caution is necessary in order to avoid communi- 
cating this disease. No medical man should go to a labor 
for at least a week after seeing a case of puerperal fever; 
and when he does go, he should take care that he has on 
no single article of dress which he wore on that occasion. 
No student should go to a midwifery case soon after dress- 
ing an erysipelatous patient, or making a post-mortem ex- 
amination, especially of a case of abdominal inflammation. 
In the Vienna Hospital a rule was made, that every stu- 
dent who had been so engaged, should wash his hands in 
chlorinated water before examining a lying-in patient. It 
is better, indeed, that students should not attend mid- 
wifery cases whilst they are engaged as dressers at hos- 
pitals ; and as regards post-mortem examinations, Dr. 
McClintock goes so far as to say that " the man who de- 
votes himself to obstetrics should abjure the study of 
pathological anatomy." 

The author is in the habit of using the Turkish Bath 
after he has been exposed to infection of any kind, and he 
can confidently recommend it as the best means of cleans- 
ing the skin and eliminating animal poisons from the 
system. 

Puerperal fever may commence within twenty-four hours 
after delivery. The most usual period of invasion, how- 
ever, is from forty-eight to seventy-two hours. Again, it 
may not come on until five or six days afterwards. 



CASES REQUIRING CONSULTATION. 151 

The pulse averages in most cases 120 to 130 beats in a 
minute ; it is usually small and feeble, but in the more 
sthenic forms is hard and wiry. [The pulse quite fre- 
quently reaches 150 or 160 in a minute.] 

The countenance in puerperal fever is very character- 
istic, and very soon assumes the Hippocratic character. 
The complexion is pale and sallow, with a hectic patch in 
the centre of the cheek. The treatment is nearly always 
unsatisfactory, and appears to have little effect in delaying 
the fatal termination. The cases most amenable to treat- 
ment are the more acute forms of peritonitis, which come 
on soon after a severe or instrumental labor, for instance. 
These bear more resemblance to ordinary peritonitis, and 
require much the same treatment, viz., bleeding, leeches, 
mercury to affect the system, opiates, and warm fomenta- 
tions. These are the cases which are most likely to re- 
cover. 

A somewhat different treatment is required in what is 
called the gastro-bilious puerperal fever (puerperal in- 
testinal irritation of Locock). Here free purgation by 
castor oil, calomel, and enemata is necessary. 

The form called uterine phlebitis is best treated by 
leeches, cataplasms, Dover's powder, and calomel to affect 
the system. The vagina should be syringed out daily, as 
recommended in Note 47, Part II. This is a most useful 
measure in all cases of puerperal fever. 

The epidemic or adynamic form of puerperal fever is 
the scourge of lying-in hospitals ; being at the same time 
the most contagious, and the least amenable to treatment. 
In this form there are sometimes no morbid appearances 
to be found after death, in the uterus, or its appendages. 
In other instances, signs of inflammation are observed, 
and occasionally purulent deposits are met with in the 
joints, orbits, etc., as in cases of pyaemia. It appears to 
make very little difference in the result, whether a stimu- 
lant or antiphlogistic plan of treatment be adopted. The 
remedies usually adopted are calomel and opium in re- 
peated doses ; turpentine both internally and as an exter- 
nal application to the abdomen ; sometimes leeches ; 
nourishing broths, wine and other stimuli, are always 
necessary to sustain the vital powers. 



152 OASES REQUIRING CONSULTATION. 

Phlegmasia Dolens — Symptoms. 

33. In cases of phlegmasia dolens. This disease 
usually comes on about ten days or a fortnight 
after delivery. It sets in with rigors, headache, 
quick pulse, restlessness, and general malaise. 
These are speedily followed by pain and tender- 
ness in the hypogastrium or groin, extending down 
the thigh and leg of that side ; the whole limb then 
becomes greatly enlarged, and at the same time 
hot, tense, elastic, white, and shining. The femo- 
ral veins and lymphatics are hard, knotted, and 
tender to the touch. There is much accompanying 
constitutional irritation, feverishness, and want of 
sleep. The tongue is furred, the face is pallid, the 
milk and lochia usually much diminished. These 
symptoms commonly pass off in two or three weeks, 
but the limb ma}' remain stiff and lame for a much 
longer period. 

There has been much discussion at various times as to 
the pathology of phlegmasia dolens, or " white leg," as it 
is vulgarly called. It now seems pretty well established, 
that the disease consists in an inflammation and obstruc- 
tion of the principal veins, and also lymphatics, of the 
limb affected ; and this inflammation, in most instances, is 
due to the imbibition of poison by the uterine veins. 

The pain and swelling do not always progress from 
above downwards. The disease sometimes commences in 
the calf of the leg, which is the seat of a violent cramp- 
like pain, speedily succeeded by swelling. 

The limb affected may increase to at least double its 
ordinary size. The swelling is so firm and elastic, that it 
very seldom pits on pressure, and is scarcely influenced in 
any way by position. 



CASES REQUIRING CONSULTATION. 153 

It occasionly happens, that, as soon as the disease has 
abated in one leg, the other is attacked, and goes through 
a similar course, except that the symptoms are scarcely 
ever so severe. In some rare cases both legs are attacked 
at once. 

The treatment of this disease consists in the application 
of leeches, followed by poultices, to the groin, or part first 
affected. Opiates are generally of great service. After 
two or three days, turpentine stupes or blisters to the 
affected parts are very useful. When the acute stage is 
past, tonics are proper, together with a generous diet. 
The affected limb may then be painted with iodine or 
rubbed with various stimulating liniments, and afterwards 
enveloped in a flannel bandage. 

Phlegmasia dolens rarely goes on to a fatal termination. 
Should it end thus, the disease in all probability has either 
accompanied uterine phlebitis, or has resulted in an attack 
of general phlebitis, followed by deposits of pus in various 
remote parts of the body. 

Puerperal Thrombosis and Embolia — Symptoms. 

34. In cases of threatened syncope from puer- 
peral thrombosis. In women who have been lately 
delivered (especially when there has been hemor- 
rhage from inefficient uterine contraction after 
labor), the sudden occurrence of dyspnoea, palpi- 
tation, and syncope is an alarming symptom, be- 
cause it usually denotes an altered condition of the 
blood, which has led to the formation of clots, and 
consequent obstruction of the pulmonary circula- 
tion. 

The pathology of puerperal thrombosis and embolia is 
very well explained by Dr. R. Barnes, in a paper which 
was published in the " Obstetrical Transactions" for 1863. 
It is thus described : — 

" 1. There is a dyscrasia of the blood immediately pro- 



]54 CASES REQUIRING CONSULTATION. 

ceeding from the puerperal process, which is favorable to 
the production of clots in the uterine veins and veins of 
the lower extremities. Imperfect contraction of the uterus, 
the formation of putrilage in the uterine cavity from the 
admission of air, which acts upon the blood and serum 
squeezed out of the vessels, and the remains of adherent 
placenta or of decidua, are often the immediate antece- 
dent conditions of peripheral thrombosis 

"2. The next step is that of embolia. Portions of the 
peripheral thrombi, attended, no doubt, in many cases, by 
septic matter derived from the uterus, are carried to the 
right heart. If the solid matters be large enough, or the 
septic or ichorous matters be irritating enough, to cause 
a violent perturbation of the heart's action, and to act 
chemically on the blood-mass, rapid coagulation of blood 
in the right cavities may ensue, followed by a similar pro- 
cess in the larger pulmonary arteries. In such cases 
sudden death occurs. 

" 3. But in those cases in which either minute portions 
of thrombi are taken up from the peripheral veins, or 
when the septic or ichorous matter is less virulent, no clot 
may form in the right heart, but minute emboli may be 
carried into the finer divisions of the pulmonary artery, 
causing lobular pneumonia, ending in slower death, or 
possibly in recovery. 

"4. It has been noticed, that in many of these cases 
some mental emotion or sudden exertion has immediately 
preceded (and has seemed to be the exciting cause of) the 
cardiac and pulmonic distress." 

With respect to the treatment of these cases, Dr. 
Barnes states : " The point of first importance is to en- 
courage lactation." " The next points are to enforce the 
recumbent position, to remove all causes of mental or 
bodily disturbance ; not to starve the patient, and thus to 
give activity to the absorption of foul matters, but to 
supply the circulating fluid with generous materials." 

The remedies adapted to these cases are stimuli and 
tonics ; wine, bark, iron, and especially ammonia, which, 
besides being a stimulant, is also believed, in accordance 
with Dr. Richardson's views, to have a powerful solvent 
action upon any clots which may have formed in the heart 
or bloodvessels. 



CASES REQUIRING CONSULTATION. 155 

Pelvic Cellulitis and Abscess. 

35. In cases of pelvic cellulitis and abscess. This 
affection comes on insidiously some two or three 
weeks after delivery or abortion. It is denoted by 
fixed pain, swelling, and tenderness, just above the 
pelvic brim in one iliac region or groin ; by hard- 
ness and tenderness, on vaginal examination, in 
the neighborhood of the os uteri, and by painful 
micturition and defecation. There is much ac- 
companying general disturbance, quick pulse, 
hectic fever, and loss of appetite. Suppuration 
is denoted by rigors and increased severity of the 
local tenderness and throbbing. The pus may be 
discharged externally above Poupart's ligament, or 
into the vagina, rectum, or bladder. This event 
usually gives relief to all the symptoms. 

In this affection the inflammatory effusion appears to 
be the result of absorption of irritant matters from the 
uterine surface. The actual seat of the effusion is usually 
the meshes of the areolar tissue surrounding the uterus, 
between the folds of the broad ligament ; but in some 
cases there is probably pelvic peritonitis present. 

The abscess most frequently bursts into the rectum or 
bladder, and the case terminates favorably. Sometimes, 
however, it escapes externally, after burrowing and form- 
ing troublesome sinuses, which cause the recovery to be 
very protracted. In som e rare instances it has been known 
to give way into the peritoueal cavity, and prove rapidly 
fatal. 

The treatment consists in topical depletion by leeches, 
warm fomentations, poultices, and turpentine stupes. The 
pain and restlessness at night should be relieved by opiates 
and hydrate of chloral, or by opiate enemata and bella- 
donna pessaries. Tonics and a nutritious diet are required, 



156 CASES REQUIRING CONSULTATION. 

especially towards the termination. When distinct fluc- 
tuation can be perceived either externally or in the vagina, 
the abscess maybe opened ; but, as this operation requires 
considerable tact and discrimination, a consultation should 
be requested. 

Puerperal Mania — Symptoms. 

36. In cases of puerperal mania. This form of 
insanity may show itself as acute mania, or assume 
the more chronic form, melancholia. The first 
kind commences very soon after labor ; the pulse 
continues very frequent, and the excitement of the 
second stage, instead of abating, increases to a 
wild delirium, which, if not relieved, may end in 
coma, paralysis, and death. The second and more 
common kind usually commences two or three 
days after labor, when the flow T of milk sets in, or 
at a still later period ; and is very apt to assume 
the form of religious melancholy. The patient is 
captious, suspicious, and liable to take sudden and 
unaccountable aversions to those about her. The 
bowels are usually constipated, and the secretions 
much vitiated. If fever be present, it is of a low 
form, and there is a general want of power in the 
system. 

When the acute form of puerperal mania terminates 
fatally, the post-mortem appearances usually found are — 
thickening and opacity of the cerebral membranes, to- 
gether with vascularity, softening, and effusions of blood 
or serum in the brain or membranes. This form appears 
in some instances to be nothing more than a particular 
kind of puerperal fever. In the chronic form there is 
usually headache, offensive breath, a sunken appearance 



CASES REQUIRING CONSULTATION. 157 

of the eye, and pallor, or sallowness of the countenance. 
If there is any accompanying fever, it is of a low type. 
This kind appears to be mostly connected with derange- 
ment of the digestive organs. In other instances it has 
been clearly traceable to exhaustion, arising from profuse 
hemorrhage during labor, or from over-lactation. In the 
first kind of puerperal mania, an antiphlogistic treatment 
is proper, such as leeches, and cold to the head, warm 
pediluvia, and smart purgatives. In the other kind, pur- 
gatives are necessary; and afterwards great attention 
should be paid to diet, and to the regulation of the bowels. 
In both kinds, should sleep be absent, sedatives will be 
required ; but for this purpose hydrate of chloral is pre- 
ferable to opium, which often tends to increase the cere- 
bral excitement. In those cases which appear to be the 
result of exhausting discharges, the patient should be put 
on a generous diet, and a course of tonics. Sedatives are 
also of much service. If over-lactation appear to be the 
cause, the child must be weaned. 

[The two remedies upon which we are to place 
our hopes, both in this terrible form of disease 
(mania) and in that so closely allied to it (puer- 
peral fever), are opium and the lancet. Leeches 
do but little good in well-marked cases. The 
patients should be bled out of the disease, so to 
speak. From 18 to 28 ounces will show its good 
result. This should be followed by a large dose 
of opium. Calomel combined with the opium often 
proves of great service. 



14 



PART IV. 



CHAPTER I. 

DISEASES OF PREGNANCY. 

While there are certain symptoms which a 
woman is taught to believe to be really necessary 
signs of pregnancy, and to regard as absolutely es- 
sential to such a state, yet, perhaps, there is no 
condition in the life of the female, which needs 
more the sympathy and care of the physician than 
this. Realizing this, and that so many circum- 
stances herein arise, so perplexing to the young 
physician, I have added this chapter to the few 
suggestions already given in a former edition. 

Under this head it must be remembered, that 
the effects of pregnancy are varied. You will find 
Mrs. A., a delicate frail woman, nervous, anaemic, 
and weak. She becomes pregnant, her form be- 
gins to be rounded, her nervous system rallies, her 
pale, wan features begin to be lighted up, and she 
steadily improves during the whole period of ges- 
tation. Mrs. B., on the other hand, a strong robust 
woman, naturally presenting every evidence of 
health, under like circumstances gradually or 



DISEASES OF PREGNANCY. 159 

rapidly fails in all physical respects, until labor 
actually sets in. Therefore, while salutary and 
beneficial results may fall to the pregnant woman 
in the one case, and most harassing in another, 
yet there are certain general symptoms largely 
common to all, and which are discussed in our 
text books under the head of diseases of preg- 
nancy. 

One of the first and most common of these is 
morning sickness. Sometimes this troublesome 
affection occurs in the early months of pregnane}', 
ceasing at the period of " quickening ;" again, it 
may arise for the first time shortly after quicken- 
ing, and continue until labor sets in, or occasionally 
it will last throughout the entire pregnancy. It is 
called morning sickness, from the fact that the 
woman rarely feels it prior to rising in the morning 
from her bed, and scarcely ever does it continue 
more than three or four hours. A slight morning 
sickness is generally expected, but not unfrequently 
it becomes exceedingly troublesome, and the physi- 
cian is summoned to give relief. 

A teaspoonful of nicely prepared charcoal, with 
a scruple of magnesia, will generally bring ease. 
If the bowels are constipated, a mild saline cath- 
artic should be given. Kissengen or Yichy water, 
or even Epsom salts, will prove serviceable. 

Very often two or three tablespoonfuls of strong 
coffee, without sugar or milk, will, if taken before 
rising, bring most happy relief. Prof. Simpson's 



160 DISEASES OF PREGNANCY. 

remedy, oxalate of cerium, has lost none of the 
credit he attributed to it when first he introduced 
it to our notice. Alone in one grain doses, or 
combined with Subnit. Bismuth, or even in four or 
five-grain doses, as has been more recently recom- 
mended, it proves one of the most efficient reme- 
dies we have for the treatment of this troublesome 
affection. 

Heartburn. — This word, commonly used, brings 
only an idea of temporary trouble, and that, from 
its common prevalence, of very little moment; but 
to the obstetrician it means a great deal, and forms 
one of the most troublesome diseases — for disease 
it becomes — of pregnancy. It may occur at any 
part of, or during the entire time of pregnancy. 
It needs no description, and its relief, not cure, 
must be brought about by alkalines. Very often, 
however, when the ordinary alkaline treatment 
failed, I have given great relief to the patient by 
two-drachm doses of Hosford's hypophos. lime 
before meals. 

Costiveness. — Best treated by simple injections 
of water, repeated at a regular hour of the day. 
Do not accustom your patient to cathartics. 

Diarrhoea. — This, the direct opposite of the 
above, is by no means an uncommon complaint of 
the pregnant woman. A lady, in whose four con- 
finements I have been the medical attendant, al- 



DISEASES OF PREGNANCY. 161 

ways, during her pregnancy, suffered from this 
complaint, and such cases are not uncommon ; and, 
while it is best not to suppress it too decidedly, 
you must be on your guard, lest the patient's 
strength wanes under its continuance. 

Ipecac, and Dover's powder, combined in small 
doses of each, answer a good purpose unless con- 
tra-indicated by obstinate nausea and vomiting. 
Rhei syrup, in conjunction with a few grains of 
bicarb, soda, often gives immediate and happy re- 
lief; or, perhaps, an astringent bitter tonic slightly 
stimulated will answer the purpose best. Regu- 
lation of the diet forms an important part in the 
successful treatment of such disturbances. 

Fainting Fits ; Palpitation of the Heart. — 
These are common disturbances of the pregnant 
state. About the period of quickening, the fainting 
fits are most frequent. Generally these attacks are 
traceable to some direct cause, such as over- 
exertion, mental or physical excitement, and the 
like ; but sometimes the attack is sudden, and 
no cause is apparent. During the spasm place 
the patient in a recumbent posture, and manage 
her as in ordinary faintness, applying ammonia 
near (not directly to) the nose, giving free air and 
slight stimulation. 

After the spasm, if it has been traceable to any 
cause, of course the removal of this will probably 
prevent a future attack. Direct the patient to 
14* 



162 DISEASES OP PREGNANCY. 

avoid all scenes of excitement, large crowds, and 
over-heated rooms. A slight stimulant in the early 
morning answers a good purpose, but, if the patient 
is of a nervous temperament, use the bromides 
freely. 

Should she be afflicted with palpitation of the 
heart, means must be employed to prevent, if pos- 
sible, future attacks. If these troubles occur 
during pregnancy for the first time, probably no 
better remedies can be used than the chalybeates. 
The disease is here a functional one purely, and 
brought about by her peculiar condition. Let her 
strength be built up by a nourishing generous diet, 
and iron in some form freely administered. It 
may be well to notice briefly an idiosyncratic con- 
dition of some women. The ferruginous prepara- 
tions generally act as astringents, but occasionally 
the reverse is the case. I have had in my care 
a patient, to whom if the smallest doses even of 
any of the irons were given, would be prostrated 
with diarrhoea. Such cases are not unfrequent, 
and the young physician should remember this, 
lest, in the administration of such remedies, a 
dangerous condition may be produced. 

In the strong and plethoric woman, affected thus 
with palpitation of the heart, bromide of ammonium 
or potassium may be used with good success. 

Remember, in all such affections which arise 
during pregnancy, nothing is more important in 
bringing comparative comfort to your patient than 



DISEASES OF PREGNANCY. 163 

observing the rules of hygiene. As a general plan 
pure air and regular exercise will bring her 
comfort when nothing else will. 

These few troubles, which I have necessarily 
briefly noticed, are those most common to the 
pregnant state, and to which the physician's atten- 
tion will be most frequently attracted. 

Many others, e. g. swelling of the limbs, varicose 
veins, sudden and violent movements of the child, 
sleeplessness, piles, extreme tension of the abdo- 
men, etc., will demand the care of the physician at 
times, but those to which I have called attention 
are the diseases most frequently requiring the care 
of the physician. 

Let the young physician always remember this, 
when you are called to the pregnant woman, realize 
that you are dealing with a condition demanding 
your anxious care and warmest sympathy. Let 
your patient be in the home of wealth and luxury, 
or in the hovel of poverty and extreme want, the 
symptoms of suffering and pain may be equal, and 
will equally demand your kindest care as a physi- 
cian. 

The simple suggestions offered to you in this 
and the two subsequent chapters go to you with 
most earnest desires, that, under your care, pain 
and suffering may give place to ease and comfort. 



1G4 CARE OF THE NEW-BORN INFANT. 



CHAPTER II. 

CARE OF THE NEW-BORN INFANT. 

The few words devoted by the author to this 
topic, though thoroughly practical in character, 
seem hardly sufficient for so important a subject. 
I have, therefore, introduced this chapter to afford 
some general rules to guide the student, or those 
just entering the profession, in the management of 
the new-born child. Too often the physician is 
utterly ignorant of the duties of the nurse. Too 
frequently the little stranger, as soon as born, is 
rolled in flannel and placed by the mother's side, 
or on the lap of nurse or friend, its loud cries an- 
nouncing to the household its advent, and here the 
physician leaves it, without directions to nurse or 
mother as to its further care or management. 

It is not to be supposed that the physician is to 
wash and dress it, but he should be familiar with 
the entire care, and give directions to the nurse 
accordingly. You will not unfrequently be ques- 
tioned by the nurse or the mother upon some or 
all of these points, and with them you must be 
familiar, if 3^011 would maintain a good name 
among those who employ your services. 



CARE OF THE NEW-BORN INFANT. 165 

Let us suppose the cord has been properly tied 
and severed, as noticed on page 36, and the nurse 
is now at liberty to attend to the wants of the 
child. She should be made familiar, first, as to 

Washing the Infant. — She should be provided 
with a soft sponge, Castile soap, sweet oil, and an 
abundance of warm water (96° or 98°). It is best 
that this first washing should not be protracted, 
that it may be perfect as to result. The one fol- 
lowing will prove effectual wherein this one fails. 
Many infants are covered with a white, cheesy 
coating (vernix caseosa) — a secretion from the se- 
baceous follicles — which oftentimes is difficult to 
remove. Let the child be ivell oiled prior to wash- 
ing, and the warm water, with soap, will readily 
remove it. The nurse must remember that the 
cutaneous surface is very delicate, and must be 
gently handled, lest abrasion occur. Such result 
often manifests itself after harsh handling, and is 
the cause of great discomfort to the little one. 
The surface should be thoroughly dried with a soft 
towel gently applied. There are various powders 
in use among nurses, some of them injurious from 
the means of scenting used by druggists. Finely 
levigated white lead has been used — itself a poison 
— and a case is recorded by Koop, in which death 
resulted from the use of this powder. Nothing 
better can be used than finely-powdered starch, and, 
if there is any excoriation, as there often is about 



166 CARE OF THE NEW-BORN INFANT. 

the anus and vnlva and groins, equal parts of pow- 
dered chalk and calamine (zinci carbonas) may be 
used with great benefit. Notice should be taken 
of the cord, that there is no bleeding from it after 
the child is washed. 1 The nurse should direct her 
attention now to 

Dressing of the Infant. — They are exceedingly 
susceptible to the impressions of cold. There is a 
popular error, which has led to not a few fatal re- 
sults, that the child, even newly born, has great 
power of generating heat. Let it be remembered 
that in all warm-blooded animals there is less power 
of generating heat and resisting cold at birth, than 
at any time during life. This principle must be 
remembered and regarded, and, in a climate so 
variable as our own, the child should be carefully 
protected from cold and dampness. A soft flannel 
binder is placed around the belly of the child, fast- 
ened comfortably behind by tapes. 

If in winter, the child's neck and arms should 
be covered. This delicate skin, which fond mothers 
are so anxious to display uncovered, is particularly 
sensitive to the action of cold, and you should im- 
press it upon them, that it is a dangerous prac- 
tice to allow bare neck and limbs. " A little more 
common sense, more sleeves, and sacks, and high 

1 A most excellent powder, and one which I have largely 
used, may be made as follows : I£. — Starch |j ; Zinci Oxid. 
5j. M. Finely powdered. 



CARE OF THE NEW-BORN INFANT. 167 

dresses, arid less vanity and fashion," and mothers 
will have fewer little graves to weep over. 

If in summer, the child should be kept cool, both 
by day and night. Inattention to this latter point 
leads largely to cholera infantum. Remember the 
simple rule laid down by Churchill : " As regards 
the dress, the infant requires softness, looseness, 
and warmth, and as regards handling, gentleness 
and dexterity." 

The child washed and dressed, you will be asked 
respecting the 

Physic for the Child. — The beautiful harmony 
which Providence arranged in the action of the 
various organs of the body, and the wonderful dis- 
play of His care and wisdom manifested in the 
entire construction of beings, is shown no less 
plainly in the secretion of the breasts, even from 
the very moment the mother gives birth to her 
child. In a healthy woman, from the birth of 
tbe infant, there is a secretion of the mammary 
glands. Though this secretion is different, during 
the first forty-eight, or even seventy-two hours, 
from that subsequent to this time, still it is evi- 
dently designed for the new-born babe. This pecu- 
liar secretion (during the first two or three chiys) 
is known as colostrum, differing from pure milk, 
from the fact that it contains even a larger amount 
of solid ingredients, and a large quantity of oily 
matter — oil globules. It fulfils two purposes. 



168 CARE OF THE NEW-BORN INFANT. 

First, it affords, when freely secreted, ample 
nourishment for the child, and secondly, it acts as 
a purgative, cleansing the bowels of that dark 
green matter first passed by the infant, known as 
meconium. 

Remembering this, it is best not to give any . 
physic for the child ; but, whenever it is absolutely 
necessary, from the fact that the colostrum fails to 
purge, no remedy is equal to fresh castor oil, given 
a half teaspoonful at a dose. 

Pood for the Child. — How soon shall the infant 
be put to its mother's breast? You will often have 
this question asked you, and you have many ex- 
cellent authorities to guide you. 

I think it is safe to assert, that, provided the 
mother has passed through her labor without un- 
toward symptoms, such as unusual pain and great 
fatigue, consequent upon lingering labor, the child 
should be given the mother to nurse within three 
or four hours after labor. Nurses and mothers 
will generally oppose you in this course, avowing 
" the child will starve ;" " I have no milk ;" " can- 
not we give it sugar and water ?" Such remarks 
will constantly greet you in the lying-in room. 
The health and comfort of both mother and child 
lie to a great extent in your hands. Mark out your 
rules plainly, and see that they are followed, and, 
under the circumstances already noticed, let the 
child depend upon the mother's breast for nourish- 



CARE OF THE NEW-BORN INFANT. 169 

ment. Should it be necessaiy, under other circum- 
stances, to feed the child, the best and most con- 
venient substitute is cow's milk. This should be 
diluted with an equal quantity of water, and a 
little sugar should be added, as the milk of the 
cow possesses less saccharine matter than found 
in human milk. Care must be taken that the milk 
is of the proper temperature. It should be 95° or 
96°. Be sure that sugar and water, molasses and 
water, catnip tea, etc. — remedies which the nurses 
are so fond of giving — are avoided. No child 
should be allowed to nurse oftener than once in 
two hours. As the mother commences in this 
regard, so she must continue. 

Cleanliness of the Infant. — In its early life it 
should be bathed at least once in the twenty-four 
hours, in water from 96° to 98° Fahrenheit. The 
surface should be thoroughly dried, especially 
about the groins, perineum, and axillae. 

The discharges from the bladder and bowels, so 
frequent in early life, require as frequent change of 
napkins. This is too often overlooked by the 
nurse. Not only after each discharge from the 
bowels, but after every one from the bladder, the 
child should have applied a clean, dry napkin — not 
one that has been soiled by urine and then hung be- 
fore the fire or beneath the sun's rays to dry with- 
out having been washed ; it is the application of 
these that causes nearly all the abraded and exco- 
15 



170 CARE OF THE NEW-BORN INFANT. 

riated perineums and vulvae of children, many cases 
of which are extremely distressing. Should such 
a case present itself to your notice, inquire into 
this matter, and you will almost always find its 
cause. Every napkin should be properly washed 
prior to use, and in no room in which are confined 
mother and child, should be hung the soiled cloths. 
I have noticed this subject somewhat fully, for I 
have too often seen the evil results from inatten- 
tion to it. A good nurse will give her attention to 
these points, but unfortunately we have but few 
good nurses. 

I have thus, in a familiar and general manner, 
given you a few directions as to the care of the 
child during your attendance upon the mother, 
subsequent to her labor. It is only during these 
few days that you will be able to give your personal 
attention to these matters. By observing these 
few rules, the health and comfort of the child will 
best attest their value. 

Later Care of the Child. — It is not my inten- 
tion to enter upon the discussion of the diseases 
incident to children. Would that I had the power 
to throw some light upon this dark field. Now, as 
ever has been, the mortality of infants is the op- 
probrium of the Divine Art of Healing. The late 
Dr. Dickson asked in vain, " How shall we prevent 
the early extinction of half the new-born children 
of men V] West truthfully asserts the appalling 



CARE OF THE NEW-BORN INFANT. 171 

fact that "at least a third of all your patients" will 
be children ; " and so serious are their diseases, 
that one child in five dies within a year after birth, 
and one in three before the completion of the fifth 
year." May it fall to the lot of some reader of this 
little volume ere long to solve this startling problem ! 
I desire, in closing this chapter, to call your 
attention to two or three points intimately con- 
nected with early infancy. 

Sleep. — The habits of sleeping or wakefulness 
will be formed early, and cling closely to the little 
subject, as it grows older. Without the proper 
amount of sleep no child can flourish. The more 
it sleeps the better for the child. It should not be 
disturbed by nurse or mother, and as is customary 
to put the child to sleep at noontime in very early 
life, so should it continue till the child can walk 
about. It should not be held while sleeping, but 
laid upon the bed and warmly covered. The natu- 
ral condition of the infant, in its early life, is sleep, 
and for no reason should it be disturbed. 

Diet of the Mother. — You will often be ques- 
tioned respecting this subject. I am satisfied it is 
best not to stint the mother too rigidly in this re- 
gard. Let her live upon a generous diet, and not 
avoid articles containing acid. The child soon be- 
comes accustomed to the mother's routine of living, 
and thrives, whereas, if too much restraint is placed 



172 CARE OF THE NEW-BORN INFANT. 

upon her, every little digression from her rule af- 
fects the child. 

Colic. — The names of all the remedies brought 
into notice by quacks for this affection of infancy 
would almost fill a volume of this size. Caution 
your patients to avoid the use of these nostrums 
for their children. The basis of all is opium, and 
all tend to harm. Every child will have more or 
less of colic, and many times will be relieved by 
the application of a hot flannel to its belly, or the 
administration of a little fennel water, or a few 
drops of gin and water. If the colic continues be- 
yond the age of two or three months, and is ac- 
companied with green discharges from the bowels, 
I have found the following prescription to be of 
great service: — 

R. — Creasoti, gtt. j. 

Tr. opii, gtt. iij. 

Testa prep. 9j. 

Spts. lav. co. gtt. xl. 

Pulv. acacise, gj. 

Aquae destjllat. giss. — M. 
S. — Shake well. Teaspoonful every 3 hours. 

Infants, even from birth, are liable to constipa- 
tion. Much harm is done by the early and con- 
stant administration of purgatives. To obviate 
the difficulty, an injection of tepid water should 
be given, and always at the same hour in the day; 
allowing not more than twenty-four hours to 
elapse without an evacuation of the bowels. 

The child should be allowed the fresh air as much 



ABORTIONS. 173 

as possible, when the weather permits. Much of 
the health of the child depends upon the simple 
rules of hygiene, and to enforce these is the duty 
of the philosophic physician. It is a blessed gift 
to be able to cure disease, but to prevent it thrice 
blessed. 



CHAPTER III. 



ABORTIONS. 



It is almost impossible for one to engage in the 
practice of our profession at the present time, es- 
pecially in large towns or cities, without noticing 
to what an alarming extent the crime of induced 
abortion has reached. Scarcely a tyro enters 
upon his new work in the field of medicine ere he 
is asked to produce abortion, and the request is 
made, perhaps, by those who are little suspected 
to be guilty of so heinous a crime. Husbands 
seek it for their wives, libertines ask it for their 
mistresses, seducers seek it for the unhappy vic- 
tims of their licentious passion, wives, aye, mothers, 
even beg it for themselves. The young and old, the 
rich and poor, the nominal Christian &\\(\ the sinner, 
alike will seek you out, and with the most ingenious 
stories plead for this object. You must be pre- 
pared to meet them, and to follow a noble course. 
15* 



174 ABORTIONS. 

I know too well, that there are those who, even 
under the garb of a guardian of human life, accept 
the proffered fee, though " steeped in blood and 
crimsoned with shame,' 7 and yield to the claims 
advanced ; but as a class the medical profession 
nobly stand aloof from such deeds. 

I do not introduce this chapter to afford its 
readers a moral lesson. I would it were in my 
power to add something to what has already been 
said and written, upon this subject, that would 
show to womankind its dark guilt and its deep 
crime. I would I could impress upon their minds 
the absolute truth, that it is quenching immortal 
existence ; that it is destining what God created 
in His own image ; that it is bringing to their 
households dark, gloonry clouds, instead of pure 
and peaceful sunshine. But this is not my object 
here. I desire briefly to show to some extent its 
appalling prevalence, and then, as briefly, to lay 
down some general rules, to guide you in your 
treatment of such cases. 

Those who practise in well-settled communities 
will not unfrequently be summoned to attend those 
who have been in the hands of an abortionist, and 
who now rely upon them to relieve them from their 
sufferings and danger. None of these cases are 
without peril. The deed has been done, and now 
you are forced to attend them. Such cases should 
never fail to receive your care and attention. 

I fear, though I am ashamed to state it, the crime 



ABORTIONS. 175 

is more prevalent in our own country than in any 
other of the world. 

Since I wrote the above words, my intimacy with 
physicians in cities and towns of small size leads 
me to state that abortions are proportionally as 
common there as in large cities. 

The distinguished Prof. Hodge of this city writes: 
14 We blush while we record the fact, that in this 
count iy, in our cities and towns, in this city, where 
literature, science, morality, and Christianity are 
supposed to have so much influence; where all the 
domestic and social virtues are reported as being 
in full and delightful exercise; even here, indi- 
viduals, male and female, exist, who are continually 
imbruing their hands and consciences in the blood 
of unborn infants." 

This is, alas, too true, and the legal authorities 
not only sanction, but by cognizance encourage 
this great crime. The Rev. Dr. Todd writes : " I 
would not advise any one to challenge further dis- 
closure, else we can show that France, with all her 
atheism, that Paris, with all her license, is not so 
guilty in this respect, as is staid Xew England, at 
the present time." 

Dr. Blatchford, of Troy, X. Y., writes : " A crime 
which forty years ago, when I was a 3'oung practi- 
tioner, was of rare and secret occurrence, has be- 
come frequent and bold. 7 ' 

If we compare Xew York city with Paris, we 
shall find that " the ratio of foetal deaths to the 



176 ABORTIONS. 

population has swollen from 1 in 1633, in 1805, to 
1 in 340, in 1849, while in France, in 1851, there 
was only about 1 in 1000 ;" we shall find, secondly, 
that "the foetal deaths, as compared with the total 
mortality, had increased from 1 in 37, in 1805, to 
1 in 10.5, in 1868;" and, thirdly, that " the re- 
ported early abortions, of which the greater num- 
ber escaped registry, bear the ratio to the living 
births, of 1 in 4.04, while elsewhere they are only 
1 in 18.5 ;" and, lastly, that " early abortion, bear- 
ing the proportion to the still-births at the full 
term of 1 in 10.2, in 1846, has increased to 1 in 
4.02, in 1856." 

" In this description of New York, we have that 
of the country." 

I have thus led you to view these statistics, to 
show you the appalling extent this crime of foeti- 
cide has reached. I write to you at this day with 
sorrow, stating that this terrible crime is not less- 
ening, but is steadily, fear fully, rapidly increasing. 
I trust these facts may excite you to take your 
stand nobly with those who are battling against 
a crime, at once so wicked in the eyes of the Crea- 
tor, and so ruinous to individuals, communities, 
and to our country. 

Let us suppose you have been summoned to the 
bedside of one who is pregnant, who tells you she 
is now aborting or miscarrying, let the case be ac- 
cidental or intentional. What are the symptoms 
that will be presented ? (I desire only to speak of 



ABORTIONS. 177 

those cases where abortion is conceded, and there 
is no longer any hope of restraining it.) The two 
sjnnptoms which are always present, and to w r hich 
you must direct } T our attention, are pain and hemor- 
rhage. From the latter symptom, the patient may 
be apparently moribund when you reach her, and 
yet your prompt attention and treatment may save 
her life. If the case be one in which abortion has 
been purposely produced, boldly take the right 
stand at the onset, and give the husband or friends 
to understand that death may occur, and if so you 
shall insist upon a coroner's inquest. If this stand 
is taken, it w T ill accomplish much towards checking 
the crime. Enjoin upon your patient perfect rest. 
At once make your examination of the uterus. 

You may find the os soft and well dilated, or 
rigid and undilated. The ovum may be protrud- 
ing, or still within the uterine cavity. 

Your afrn must be to free the uterus of its con- 
tents. If the os is sufficiently dilated, you can 
easily accomplish this with your fingers {the best 
uterine instrument) or by Bond's placental forceps, 
Simpson's uterine gouge, or the curette of Recamier, 
or even by the ordinary uterine forceps. 

But if the os is closed and undilatable, you must 
bring on rapid and powerful uterine contractions, 
for upon these alone the arrest of the hemorrhage 
depends. 

The cold douche on the belly, or ice-water injec- 
tions, will sometimes accomplish this object, but 



IIS ABORTIONS. 

the two remedies upon which you are to place 
most reliance are the tampon and ergot. The 
former has already been described on page 119. 
The entire vaginal passage should be filled, and 
allowed thus to remain from three to eight hours. 
At the end of this time the tampon should be re- 
moved, and, if the os is not sufficiently dilated, 
another should be inserted, taking care that the 
bladder is freely emptied of its contents. When- 
ever the os is dilated sufficiently for your manipu- 
lations, take care that you remove all of the ovum 
and placenta, for as long as any fragment is left 
within the uterus the hemorrhage will continue, 
and endanger the woman's life. Dr. 0. P. Rex, of 
this city, recently related to me the history of a 
case under his care, in which the placenta had been 
allowed to remain nearly seven months after the ex- 
pulsion of the ovum, during the whole of which time 
the woman bled profusely, and was almost in a 
dying condition when he was first summoned to 
her relief. Ergot is one of our most efficient reme- 
dies in these cases. The fluid extract may be given 
in drachm doses every hour, in cases of profuse 
hemorrhage. 

With these two remedies at your hands — the 
tampon and ergot — you will master your case. 

After Abortion. — The treatment after abor- 
tion is similar to that after labor. Perfect quiet 
and rest, and the, recumbent posture, should be en- 



ABORTIONS. 179 

joined, and 3-011 should, in cases where the hemor- 
rhage has entirely ceased, employ large doses of 
opium. The fluid forms are best, as more quickly 
absorbed. Never give opium unless you are sure 
the uterus has contracted. The application of cold 
to the vulva as well as injections of cold water by 
vagina and rectum, are valuable adjuvants. Upon 
the first intimation of a return of hemorrhage, 
have recourse to ergot. 

If by the means mentioned you fail to dilate the 
os sufficiently, sponge tents or the sea-tangle may 
be used, a small one being introduced first, and 
allowed to remain eighteen or twenty hours, and 
then a large one inserted. In this, as in other af- 
fections requiring the use of the tent, not more 
than three should be used consecutively, as more 
than this number are apt to produce metritis. I 
have found the sponge tents to be safer and better 
than the sea-tangle. The offensive odor arising 
from the use of the tent ma} r be destroyed by using 
those containing carbolic acid or permanganate of 
potassa, or by the use of cotton or sponges satu- 
rated with glycerine. 

It has been a source of very great gratification 
to me to read the notices of the various journals 
regarding this brief chapter on Abortions. I ap- 
preciate it most keenly, and my earnest hope and 
desire is that such a stand may be taken by the 
medical profession of America as to crush this vice 
forever.] 



INDEX. 



Abortion, diagnosis of 

induction of .... 

frequency of .... 

treatment of .... 

with retention of part of the ovum 

with profuse hemorrhage 

after-treatment .... 
Abortions . . . 

After-pains 

Arrest of head in pelvis 
Artificial respiration .... 
Ascites of foetus .... 

Asphyxia of infant . 
treatment of . 



PAGE 

52 
175 
175 
32, 177 
118 
118 
178 
173 

98 
127 

90 
134 

88 

89 



Bandage after labor .... 
Barnes, Dr. R., on puerperal thrombosis 
Bed during labor, how to guard . 
Belladonna, use of, as an anti-lactescent 
Body, expulsion of . 
Breasts, inflammation of 

treatment of ... 

Breech presentations, mechanism of . 

diagnosis of . 

evils of early interference in 

management of . . 
16 



43 

153 

27 

110 

36 

112 

113 

68 

70 

71 

71 



182 



INDEX. 



Breech presentations, arrest of body in 

arrest of head in . 
Brow presentation .... 
Brown, Mr. I. B., on lacerated perineum 



Calculus in bladder during labor 
Care of the new-born infant 
Catheterism during labor 
Churchill, Dr , statistics of first stage 
presentations 

on the pulse after labor 
Cleanliness of the infant 
Colic of the child 
Colostrum . 
Convulsions, epileptic 

hysterical . 

apoplectic 

treatment 
Cord, umbilical, see Funis 
Costiveness 
Cramps during labor . 

Death of foetus . 
signs of 
labor after 
Deformities of pelvis . 
Diarrhoea . 
Diet during labor 

after labor . 

of the mother 
Diseases of pregnancy 
Dressing the infant 

Ephemeral fever 
Ergot of rye 



INDEX , 



183 



Extension, movement of 
Extra-uterine pregnancy 

Face presentations, mechanism of 
diagnosis of . 
management of 
Fainting fits 
Ferguson, Dr., on puerperal fever 
Fever, puerperal 

treatment of . 
Flooding, see Hemorrhage 
Foetus, death of . 
viability of . 
Food for the child 
Foot presentations 

diagnosis of . 
management of 
Funis, ligature and division of 
bandaging of 
coiling of, round neck . 
prolapse of . 



Gooch, Dr., rules for leaving during labor 
on post-partum hemorrhage 

Hall, Dr. M., on the cold douche 

method of performing artificial respiration 
Head, rotation of 

expulsion of 

interval after birth of . 
Heartburn .... 
Hemorrhage after delivery . 

symptoms of 

treatment of 



184 



INDEX. 



Hemorrhage, internal . 

secondary .... 

accidental .... 

unavoidable 
Hewitt, Dr. Graily, on support of the 
Hydrocephalus .... 



penne 



Imperforate os uteri . 
Incontinence of urine after delivery 
Inertia of uterus in twin cases . 
Infant, care of the new-born 

washing the 

dressing the 

physic for the 

food for the .... 

cleanliness of the 

later care of 

sleep of ... . 
Instruments, etc., required during labor 
Inversion of uterus 

treatment of . 

Knee presentations, diagnosis of 
management of 

Labor, signs of commencing 
premonitory signs of . 
first stage of 
prompt attendance to . 
preliminary observations of 
prognosis of 
second stage of . 
management of, during pains 
third stage of 



INDEX. 



185 



Labor, diet during .... 
diet after ..... 
questions during .... 
mode of ascertaining progress of . 
repose after ..... 
premature ..... 
tedious, causes of 

from loaded rectum 
from inefficient uterine action 
from want of sleep 
from rigid os uteri 
from premature rupture of membr 
from cedematous os uteri 
from toughness of membranes 
from rigid soft parts 
from unfavorable presentations 
from want of room 
from anterior obliquity of uteru 
powerless ..... 
Laceration of perineum 
Later care of the child 
Lee, Dr., on puerperal fever 
Lochia! discharge .... 
deficiency of . 
excessive . . . 
offensive .... 

Mania, puerperal .... 

Membranes, rupture of 

how to remove .... 
Merriman, Dr., on twin cases 
Miliary fever ..... 
Milk, secretion of ... . 

substitute for .... 
16* 



1SG 



INDEX. 



Milk, how to get rid o 
fever . 

treatment of 
Mole pregnancy . 
Monsters 
Mother, diet of the 

Nervous shock . 

treatment of 
Nipples retracted 
sore 

treatment 



Os uteri, state of, in first stage 
in second stage 
in primiparse and in multipara 
how to distinguish 
imperforate . 

Pains, spurious, diagnosis of 

treatment of 
Paralysis of legs after labor 
Patient, during labor, when to leave 

time for leaving after labor 

visits to, after labor 

inquiries respecting 

management of . 
Pelvis, deformities of . 
Pelvic cellulitis and abscess 

tumors 
Perineum, support of . 

laceration of 
Phlegmasia dolens 
Physic for the child . 



INDEX. 



187 



Placenta, expulsion of 

danger of forcibly detaching 

how to ascertain detachment of 

battledore . 

how to remove 

retention of . 

retained, treatment of , 

prsevia, diagnosis of 
treatment of . 
Position during first stage 

second stage 
Powerless labor . 
Pregnancy, diagnosis of 

diseases of . 
Presentation, diagnosis of 

head, signs of 

ordinary 

forehead anteriorly 
diagnosis 
mechanism 

face 

breech 

brow . 

where none can be felt 
.upper extremity 

placenta 

foot 

knee . 

compound . 

hand with head 

hand with breech or foot 
Prognosis, in natural labor 
Prolapse of bladder during labor 

of fundus . 
Prolapsus uteri . 



188 INDEX. 



Puerperal convulsions 

fever . 

treatment of . 

mania . 

thrombosis . 
Purgative after delivery 



Ramsbotham, Dr., on occipito-posterior presentations 
Rest after delivery, use of . 
Restitution, movement of . 
Retention of urine during labor 

after labor ...... 

of placenta 

treatment of . 
Rigby, Dr., on post-partum hemorrhage . .# 

on pelvic deformity ..... 
Rigors after labor ...... 

Rotation, movement of 

Rupture of uterus 



Scalp, tumor of 

Shoulders, rotation of ..... 

presentation of . 
Simpson, Dr., on detachment of placenta prsevia 
Sleep of the child . . . . 
Smith, Dr. Tyler, on treatment of post-partum hemor- 
rhage ........ 

Stage, first, signs of 

pains during ..... 

position during 

second, signs of 

position during ..... 
management of 
third, duration of 



INDEX. 



189 



Stillborn children, management of delivery with 

Strictures of vagina . 

Sylvester, Dr., method of performing artificial r 

ration ..... 

Tedious labor from want of room 

Tumors in pelvis 

Twin births, mechanism of 

diagnosis of . 

management of 

Uterus, state of, during third stage 

after expulsion of the placenta 

prolapse of . 

rupture of . 

inversion of 

treatment of . 

Vagina, normal state of 
strictures of 
state of, in second stage 
Vaginal examinations, how to make 
when to make 
information derived from 
frequency of 
Vienna Hospital, precautions in 
Vomiting during labor 

Washing the infant . 

Weid 



PAGE 

87 
122 



spi- 



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Galloway's Manual of Qualitative Analysis. From the Fifth 

English edition. 1 vol. 12mo., cloth. (Now ready.) 2 50 

Hartshorne's Conspectus of the Medical Sciences. 1 vol. royal 

12mo., with 316 illustrations; extra cloth. (Lately issued.). . . 4 50 
Same work, leather, raised bands 5 25 

HENRY C. LEA, Philadelphia. 



IMPORTANT MEDICAL WORKS, 

Hartsliorne's Essentials of Medicine. Second edition, revised. 

1 vol. royal 12rao. (Just issued.) Cloth, $2 38; leather $2 63 

Hill on Venereal Diseases. 1 vol. 8vo., extra cloth 3 25 

Hodge's Obstetrics. One large quarto vol., plates and wood-cuts. 

Cloth 14 00 

Hodge on Diseases of Women. 2d edition. Cloth. (Lately issued.) 4 50 
Hamilton on Fractures and Dislocations. 1 vol. 8vo., with 322 

cuts, extra cloth, $5 75 ; leather 6 75 

Hoblyn's Medical Dictionary. By Hays. 1 vol. 12mo., cloth.... 1 50 

Same work, leather 2 00 

Laurence and Moon's Ophthalmic Surgery. 1 vol. Svo., cuts. CI. 

(New edition, lately issued. ) 2 75 

Ludlow's Manual of Examinations. 1 vol. 12mo., many cuts, cl. 3 25 

Same work, leather 3 75 

Marshall's Physiology. One large Svo. vol., with many illustra- 
tions, extra cloth, $6 50; leather 7 50 

Mcliase's Surgical Anatomy. Imperial quarto. 1 vol., 68 col- 
ored plates, cloth 14 00 

Neill and Smith's Compendium of Medical Science. 1 very large 

vol. 12mo., 372 cuts, sheep, $4 75 ; cloth 4 00 

Odling's Chemistry. In one 12mo. vol. of 261 pp., cloth. (Lately 

issued.) 2 00 

Parrish's Pharmacy. 1 vol. 8vo., cloth, $5 00; leather 6 00 

Pereira's Materia Medica. Condensed. 1 vol. Svo., over 1000 

pages, 236 cuts, leather, $8 00 ; cloth 7 00 

Pavy on Digestion. 1 vol. Svo. (Just issued ) 2 00 

Koberts on Urinary Diseases. In one vol. Svo., of 616 pp. with 
many illustrations, and a colored plate. Cloth. (Now ready.) 4 50 

Banking's Half-Yearly Abstract. 2 vols. Per annum 2 50 

Single vols. , separate 1 50 

Ramsbotham's Midwifery. 64 plates. 1 vol. imp Svo., sheep.. . . 7 00 
Smith on Diseases of Children. 1 vol. Svo , 2d edition. (Now 

ready.) Cloth, $5 00 ; leather 6 00 

Smith on the Wasting Diseases of Infants and Children. In one 

vol. 8vo. of about 200 pp., ex. cl. New ed. (Lately issued.) 2 50 
Thomas on Women. 225 cuts. 1 vol. 8vo., 3d edition, revised 

and enlarged. (Just issued.) Cloth, $5 00; leather 6 00 

Tanner's Clinical Medicine. Enlarged edition. 1 volume, small 

12mo., cloth 1 50 

Tanner on Pregnancy. Col. plates. 1 vol. 8vo., cloth 4 25 

Thompson on Diseases of the Urinary Organs. 1 vol. Svo., cloth. 

A new work. (Lately issued.) 2 25 

Thompson on Stricture. Colored plate and 47 wood-cuts. 1 vol. 

Svo. (Lately issued.) 3 50 

Wells on the Eye. 1 vol. 8vo., of 736 pages, with col. plates and 

. 216 wood-cuts, also the test types of Snellen and of Jaeger, ex. cl. 5 00 

Same work, leather 6 00 

Watson's Practice. In two handsome 8vo. vols. From the last 
London edition, with additions by Dr. Hartshorne. (Now ready.) 

Ex. cloth, $9 00 ; leather 11 00 

West on Children. 1vol. Svo., cloth, $4 50; leather 5 50 

West on Females. 1 vol. 8vo., cloth, $3 75; leather 4 75 

Wilson's Anatomy. 1 vol. Svo., 397 cuts, cloth, $1 00 ; leather... 5 00 
Williams on Consumption. 1 vol. 8vo., ex. cl. (Lately issued.) 2 50 

Wilson on the Skin. Seventh edition, 1 vol. Svo., cloth , 5 00 

Plates to ditto, 8vo., extra cloth 5 50 

Text and Plates done up in 1 vol., extra cloth 10 00 

Winslow on Diseases of the Brain. 1 vol. Svo 4 25 

Wohler's Organic Chemistry. From the 8th German edition, by 
Ira Kemsen, M.D. 1 vol. 12mo. (In press.) 

HENRY C. LEA, Philadelphia. 



